Respiratory Examination Flashcards by Hannah Meiklejohn

What are the basic steps of the respiratory examination?

General inspection

Hands

Head and neck

Chest (lungs)

Bedside tests of respiratory function

Heart

Abdomen and legs

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What might be observed on general inspection in a respiratory exam?

“Sick or not sick”

Orientated or confused or drowsy

Respiratory distress (at rest or when moving/undressing): indicated by obvious respiratory effort, noisy breathing (e.g. stridor)

Other: febrile, sputum mug, equipment (IV treatment, supplemental O2, NIV)

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What might be observed in the hands in the respiratory exam?

Clubbing

Pallor

Radial pulse

Peripheral cyanosis

C8-T1 lesion (wasting of intrinsic hand muscles, parastheisa over hypothenar eminence and medial forearm)

Tobacco staining

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What are the signs of digital clubbing?

Increased nail-bed fluctuation

Loss of nail-fold angle (>150 degrees)

Increased curvature of long axis of nail

Soft tissue swelling (drum-sticking)

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List 3 respiratory, 3 cardiac, and 3 oher causes of clubbing

Respiratory: suppurative lung disease (e.g. bronchiectasis, TB, lung abscess), lung cancer (NSCLC), pulmonary fibrosis

NOT chronic bronchitis/COPD

Cardiac: SBE, congenital cyanotic heart disease, left atrial myxoma

Others: IBD, PBC, idiopathic

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What is the mechanism of cyanosis?

Bluish discolouration of skin +/- mucous membranes due to increased deoxy Hb (>4g/100mL)

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Distinguish between peripheral and central cyanosis in terms of their mechanism

Peripheral: circulatory insufficiency (increased O2 extraction)

Central: respiratory insufficiency (decreased O2 saturation of Hb)

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What should be looked for on examination of the neck in the respiratory exam?

JVP

Trachea

LNs (stand behind patient except when examining the supraclavicular LNs)

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Describe the surface markings for the lungs (anterior and posterior)

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What may be observed on inspection of the chest in the respiratory examination?

Not sensitive or specific BUT look for:

Chest movement (use of accessory muscles, symmetry, paradoxical movement of chest and abdomen)

Skin changes (scars, pigmentation)

Chest wall deformity (barrel, kyphoscoliosis, funnel, pigeon)

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What should be palpated for in the respiratory examination?

Degree of chest movement: asymmetry, reduced expansion (can be seen in most lung pathologies and if evident, suggests significant abnormality)

Chest wall and thoracic spine tenderness

Palpable breath sounds

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3 causes of increased percussion note

Pneumothorax

Hyperinflation

Lung cyst

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6 causes of decreased percussion note

Consolidation

Collapse (atelectasis)

Dense fibrosis

Pleural fluid/thickening

Elevated hemidiaphragm

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What are normal breath sounds called?

Vesicular

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What are increased breath sounds called?

Bronchial breathing

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What extra sounds may be heard on auscultation of the chest in a respiratory exam?

Crepitations (crackles)

Ronchi (wheezes)

Pleural rub

Describe the 3 characteristics of bronchial breathing

“Blowing” sound in inspiration and expiration

Expiration as long as inspiration

Pause between inspiration and expiration

Give 3 examples of conditions in which bronchial breathing may be observed

Consolidation (without proximal obstruction)

May be heard in collapse (atelectasis) or pleural effusion

Give 6 examples of conditions in which reduced breath sounds may be heard

Airflow obstruction

Hyperinflation

Pleural effusion

Pneumothorax

Thick chest wall

Lung collapse

Why might wheezes occur?

Partial bronchial obstruction

How should wheeze be characterised?

High or low pitched

Inspiratory or expiratory

Focal or diffuse

List 5 conditions in which wheeze might occur

Asthma

Chronic bronchitis

Pulmonary oedema

Foreign body

Lung tumour

How should crepitations be characterised?

High or low pitched

Inspiratory or expiratory

Why might crepitations occur?

Bubbling of air through secretions

Sudden opening of small airways and alveoli with rapid equalisation of pressures

List 5 possible causes of crackles

Pulmonary oedema Pulmonary fibrosis Pneumonia Bronchiectasis Atelectasis

What is pleural rub?

Non-musical sound, usually longer and lower pitch than crepitations Inspiratory with mirror image in expiration Not cleared with coughing May be palpable Often associated with pleuritic pain

What is the mechanism of pleural rub?

Sliding of roughened pleural surfaces (without intervening pleural fluid)

What are the broad causes of pleural rub?

Inflammation (infective, non-infective) Tumour

What else should be measured on auscultation?

Forced expiratory time: listen over the trachea, should be less than 3 seconds (\>6 secs indicates significant airflow obstruction)

What other regions should be examined during a respiratory examination and why?

Heart: features of pulmonary HTN, for other explanations of dyspnoea or haemoptysis Abdomen: for features of RHF, liver metastases, etc Legs: for features of RHF, venous thrombosis

What findings are expected on respiratory examination in the setting of consolidation?

Usually no shift in trachea, small change in chest movement Decreased percussion note Increased breath sounds (bronchial, +/- crepitations) Increased vocal resonance

What findings are expected on respiratory examination in the setting of pleural effusion?

Mediastinal shift (to other side) and decreased movement only if very large Decreased percussion note Decreased breath sounds Decreased vocal resonance

What findings are expected on respiratory examination in the setting of pneumothorax?

Mediastinal shift (depending on size) and sometimes decreased chest movement Increased percussion note Decreased breath sounds Decreased vocal resonance NB Can't detect clinically if small

List 8 signs seen in COPD

Respiratory distress Cachexia Cyanosis Plethoric facies Signs of hyperinflation Wheezes Signs of pulmonary HTN +/- RHF Prolonged forced expiratory time

List 4 signs of pulmonary HTN

Palpable RV heave and 2nd HS Loud S2 S4 Pulmonary flow murmur

List 3 signs of RHF

Elevated JVP S3 Peripheral oedema, ascites, pleural effusions

List 3 causes of reduced percussion note at lung base

Consolidation/collapse or dense fibrosis of lung Pleural effusion or thickening Elevated hemidiaphragm (pulled up, pushed up or paralysed)