Examination of the respiratory system

1. Examination of the respiratory system Leyla Swafe, FY1, NNUH

2. Directives • Examine the respiratory system • Examine patient´s chest

3. Overview • Introduction • Inspection • Palpation • Percussion • Auscultation • Concluding remarks • OSCE video

4. Introduction • Wash hands • Introduce, explain, consent, expose • Position: supine at 45

5. Inspection: signs • General inspection • Appearance: ill/distressed/pain/short of breath • Accessory muscles, pursed lip, wheeze, stridor • Nutritional statius: cachexia • Oxygen, fluids and medications • Sputum pot

6. Inspection/Observation: A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to: General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep? Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies some element of respiratory difficulty. Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!

7. Video – respiratory distress

8. Beside Always look for a sputum pot! Yellow/green sputum –infection Massive amounts of sputum – most likely bronchiectasis Look for signs of blood –infection/malignancy Inhalers

9. Flapping tremor http://www.youtube.com/watch?v=Rbv-zaVszlk

10. Cyanosis: A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.

11. Clubbing Clubbing: Bulbous appearance of the distal phalanges of all fingers along Concurrent loss of the normal angle between the nail base and adjacent skin. Most commonly associated with conditions that cause chronic hypoxemia (e.g. severe emphysema), also associated with a number of other conditions. However, in general it is neither common nor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing.

12. Nicotine staining

13. Pulse At the wrist you should take the patient’s pulse. A bounding pulse may indicate carbon dioxide retention. After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate. This helps to keep it as natural as possible.

14. Inspection: signs • Hands • Nails • Finger clubbing • Nicotine staining • Peripheral cyanosis • Warmth • Wrist • Flapping tremor / Fine tremor • Respiratory rate • Pulse

15. Inspection: signs • Face • Cushingoid • Eyes • Conjunctival pallor • Horners • Mouth • Central cyanosis

16. Inspection: signs • Neck • Tracheal position • Cricosternal distance • Tracheal tug on inspiration • Nodes • Palpation of lymph nodes

17. Lymphadenopathy Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow’s Node) as an enlarged node (Troisier’s Sign) may suggest metastatic lung cancer.

18. Chest wall deformities Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's ability to breathe normally. A few common variants include:

19. Palpation Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam.

20. Inspection: signs • Chest • A-P diameter • Scars • Chest drain sites • Deformity of chest/spine

21. Palpation • Trachea • Apex beat • Chest expansion

22. Chest wall deformities Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. Kyphosis: Causes the patient to be bent forward. Barrel chest: Associated with emphysema and lung hyperinflation. Scoliosis: Condition where the spine is curved to either the left or right.

23. Tactile Fremitus: Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall.

24. Pathologic conditions will alter fremitus. In particular: Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced. Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

25. Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. In this model, an infiltrate is depicted by the blue coloration that has invaded the sponge itself (sponge on left). An effusion is depicted by the blue fluid upon which the lung is floating (sponge on right).

26. Percussion • Start in supraclavicular fossa then work down • Compare side to side including axillae • Map out abnormalities

27. Auscultation

28. Auscultation

29. Auscultation Use diaphragm • Vesicular breathing (normal)/Bronchial breathing (pathological) • Decreased or absent breath sounds • Added sounds • Crepitations (cough) • Wheezes • Pleural rub • Vocal resonance • Vocal resonance ”say 99

30. Auscultation http://www.google.co.uk/imgres?imgurl=http://meded.ucsd.edu/clinicalmed/upper_cyanosis2.jpg&imgrefurl=http://meded.ucsd.edu/clinicalmed/upper.htm&usg=__vqgXEIDs3sow-yiUQEJfAhTrVEM=&h=960&w=1280&sz=167&hl=en&start=1&zoom=1&tbnid=n0NQ6CAJ2HI20M:&tbnh=113&tbnw=150&ei=fOAIUYCUFsil0AW-xoDADw&prev=/search%3Fq%3Dperipheral%2Bcyanosis%26hl%3Den%26safe%3Dstrict%26gbv%3D2%26tbm%3Disch&itbs=1 http://www.med.ucla.edu/wilkes/lungintro.htm http://www.google.co.uk/imgres?imgurl=http://www.emsjunkie.com/wp-content/uploads/2012/11/Lung-Sounds-Anterior.jpg&imgrefurl=http://www.emsjunkie.com/patient-assessment/patient-assessment-lung-sounds/&usg=__4t6XnB9CMmwFxdXfeBVg32pPHwc=&h=398&w=314&sz=60&hl=en&start=77&zoom=1&tbnid=EB1hN1Q6xG7gfM:&tbnh=124&tbnw=98&ei=zecIUZaEAqTJ0AXEwoHoBA&prev=/search%3Fq%3Dlung%2Bauscultation%26start%3D60%26um%3D1%26hl%3Den%26safe%3Dstrict%26sa%3DN%26gbv%3D2%26tbm%3Disch&um=1&itbs=1

31. General examination • Back • Sacral oedema • Ankles • Peripheral oedema

32. Causes of physical signs found on respiratory examination

33. Concluding remarks To Complete My Examination... Observation chart (BP, temp, sats) Abdominal Examination for hepatomegaly Sacral or peripheral oedema Investigations you may like to perform might include: Chest x-ray Sputum microscopy, culture and sensitivity Pulse Oximetry Arterial blood gas analysis Spirometry Peak expiratory flow rate

34. OSCE video http://www2.le.ac.uk/departments/msce/existing/clinical-exam/respiratory