Respiratory_examination_pdf.pdf

Respiratory Examination Dr. Rebecca Walmsley Clinical Programme Lead ram29 Ext 3540 Learning Outcomes  To demonstrate an understanding of the process of respiratory examination  To detect signs of respiratory pathology on clinical examination  To relate clinical signs to underlying pathology ...

Respiratory Examination Dr. Rebecca Walmsley Clinical Programme Lead ram29 Ext 3540 Learning Outcomes  To demonstrate an understanding of the process of respiratory examination  To detect signs of respiratory pathology on clinical examination  To relate clinical signs to underlying pathology  Use history & examination findings to direct appropriate treatment / investigations Examination – a quick reminder  Gather information  Refine differential diagnosis  Don’t lose sight of findings from history! – Relevant examination  Use history and examination together to help you reach a management plan Remember Your History Lecture  Presenting complaint (PC)  History of presenting complaint (HPC)  1. Chest pain  Past medical history (PMH)  Medication / allergies (DH)     2. 3. 4. 5. Dyspnoea Cough Sputum Haemoptysis  Family history (FH)  6. Wheeze  Social history (SH)  7. Systemic upset  Systems enquiry / review (SE) Respiratory Examination  Same basic structure as CVS – Introduction & explanation – Inspection – Palpation – Percussion (a new skill for respiratory) – Auscultation Introduction • Ensure adequate hygiene of hands/stethoscope • Introduce self • Confirm patient’s name and DOB • Ask patient if in any discomfort • Explain the procedure • Seek permission to examine the respiratory system - consent • Position patient appropriately (at 45 degrees) with chest adequately exposed General Inspection  Does the patient look unwell? Cachectic? In pain?  Use of accessory muscles / work of breathing  Look around the patient  Look at the patient  Listen (audible stridor, hoarseness, pattern of speech)  If any pathological signs, think: – What is the underlying cause? – How does this relate to history? – Does it increase the likelihood of respiratory pathology? Nebuliser Inhaler  Stridor - Loud, harsh, high pitched respiratory sound - Usually on inspiration - Upper airway obstruction https://www.easyauscultation.com/stridor Erythema nodosum Close Inspection and Palpation • Examine hands - inspect palpate for warmth and venodilation flapping tremor and fine tremor palpate radial pulse (rate and rhythm) • Count respiratory rate • Inspect face, eyes, mouth and pharynx Central cyanosis Central cyanosis Refn: Mind the gap: https://www.sgul.ac.uk/news/mind-the-gap-a-handbook-of-clinical-signs-on-blackand-brown-skin Tar staining Nail clubbing Nail clubbing Refn: Mind the Gap Clubbing – respiratory causes  Bronchial carcinoma  Mesothelioma  Chronic suppurative lung disease: – Bronchiectasis – Lung abscess – Empyema  Pulmonary Fibrosis  Cystic Fibrosis ‘Ruddy’ complexion polycythaemia Horner’s syndrome Horner’s syndrome  Damage to cervical sympathetic nerves  Clinical features – Unilateral miosis – Partial ptosis – Loss of sweating on same side (facial anhidrosis)  May indicate serious pathology Hands - tremor  Fine tremor – Excessive use of B-agonists  Flapping tremor – Severe ventilatory failure with CO2 retention – Hold hands outstretched – Wrists cocked-back – Look for a jerky, flapping tremor – Associated confusion Close inspection of chest / neck  Scars – cardiac surgery, thoracotomy, chest drain scars  Pattern of breathing  Shape of chest – Symmetry – Deformity (kyphoscoliosis / pectus excavatum) – Increase in A-P diameter (‘barrel shaped’)  Prominent veins on chest wall – SVC obstruction  JVP Pectus Excavatum Kyphoscoliosis SVC Obstruction Palpation of neck and chest  Lymph nodes – Examine carefully For cervical lymphadenopathy – Be systematic – Don’t rush - With patient sat forwards Palpation of chest  Subcutaneous (‘surgical’) emphysema (if appropriate) – Crackling sensation – Air in subcutaneous tissues – May be diffuse chest, neck, face swelling - Consider trauma / underlying pneumothorax (“a collection of air in the pleural cavity, between lung and chest wall, resulting in collapse of lung on affected side”)  Palpate for rib fractures if appropriate (e.g. history of chest trauma) Palpation of neck and chest  Mediastinal position – Tracheal position  Suprasternal notch  Right middle finger 2cm superior to notch  Gently press down and back  Palpate space to either side  Should be central – Cardiac apex (apex beat) - Assess for right ventricular heave Deviation of trachea Displacement towards the lesion Displacement away from the lesion Other displacement Lobar collapse Large pleural effusion Mediastinal masses Pneumonectomy Tension pneumothorax* Pulmonary fibrosis * Life threatening emergency; presents with severe symptoms/signs of respiratory distress Palpation of neck and chest  Chest expansion – Anterior and posterior (posterior when sitting forwards) – Ask patient to breathe deeply – Thumbs should move apart equally Percussion  Anterior, posterior and lateral chest  Use middle finger / left hand  Apply firmly to patient’s chest  Strike it’s middle phalanx with the middle finger of right hand  Percuss over intercostal spaces  However percuss clavicles directly  Compare left and right  Listen to note produced 23 Percussion Sites Percuss apices above clavicle using described technique then over clavicles direct Percuss intercostal spaces Percussion Percussion Note Example of possible causes Resonant Normal lung Hyper resonant Emphysema, large bullae or pneumothorax Dull Collapse, consolidation or fibrosis “Stony” or very dull Pleural effusion or haemothorax (NB If percussion note dull will need to check tactile vocal fremitus now or vocal resonance after auscultation – see end) Tactile Vocal Fremitus      Use palm / ulnar border of hand Say “99” Feel for vibration Increased fremitus - consolidation or fibrosis Decreased fremitus - pleural effusion, pneumothorax or collapse 30 Auscultation  Use bell or diaphragm of stethoscope (usually bell apices and diaphragm rest)  Ask patient to breathe deeply in and out through mouth  Listen through full inspiration and full expiration  Compare side to side – anterior, posterior and lateral (similar to percussion sites)  Listen for breath sounds and added sounds Auscultation Whilst listening ask yourself: • Are breath sounds present? • Are they vesicular in nature? • Are breath sounds equal on both sides? • Are there any bronchial breath sounds? • Are there any added sounds such as crackles, wheezes or pleural rubs? Auscultation – breath sounds  Normal = Vesicular - Intensity of sounds relates to airflow Inspiration longer than expiration Low pitched, quiet, heard over most of lung fields No gap between inspiration and expiration (however is after expiration) Diminished vesicular breath sounds • When normal lung displaced by air, e.g:  Obesity  Pleural effusion Diminished to absent  Pneumothorax*  Collapse  Hyperinflation – emphysema - in COPD *Pneumothorax can be primary spontaneous in healthy people (typically young men); secondary associated with underlying lung disease, traumatic or iatrogenic Bronchial breath sounds (abnormal)  Noise originates from larger airways  When damage to small airways / alveoli  Harsh in nature  Gap between inspiration and expiration  Expiratory component dominates  Find in consolidation – when alveoli and small airways fill with dense material (e.g. with pneumonia, infection on top of pleural effusion) or fibrosis Bronchial breath sounds I.e. Can hear similar sound over trachea as large airway Auscultation – added sounds  Crackles (formerly known as rales or crepitations)  High-pitched, discontinuous sounds  Similar to the sound produced by rubbing your hair between your fingers  Causes: Pulmonary oedema / pulmonary fibrosis / bronchial secretions / COPD / pneumonia / lung abscess / TB / bronchiolitis / bronchiectasis  Fine late crackles feature of Cryptogenic Fibrosing Alveolitis Auscultation – added sounds • Pleural rub  May be associated with pleuritic pain (sharp on inspiration / coughing)  Like “creaking leather”  Low pitched  Causes: PE / pneumonia / vasculitis Auscultation - added sounds  Wheeze      Continuous oscillation of opposing airway walls Musical quality, high pitch Implies airway (small) narrowing Louder in expiration Causes Generalised – Asthma / COPD Localised – lung tumour N.B ‘Silent chest’ in severe airways obstruction https://www.easyauscultation.com/course-contents?courseid=201 Vocal resonance  If area of dullness on percussion (i.e. not in the “normal”)  Either tactile vocal fremitus or vocal resonance – no need to do both  Use stethoscope, ask patient to say “one, one, one”  Compare with the other side. Assess quality and amplitude  Ask patient to whisper “one, one, one”. Whispering is not heard over a normal lung but in consolidation the sound is transmitted.  Increased resonance consolidation or fibrosis  Decreased resonance pleural effusion, pneumothorax or collapse (i.e. can interpret as per tactile vocal fremitus) 30 NB Often easier to do all front chest then all back I.e. posterior chest: Lymph nodes Inspection Expansion Percussion Auscultation (+/- tactile vocal fremitus and vocal resonance) 30 Other areas  Ankle oedema  Sputum pot  Observation chart – Pulse, BP, Temp, Oxygen saturation  Peak flow  Spirometry Try to make sense of findings – if mucky green sputum and fever is there an infective cause, for example pneumonia, leading onto signs of consolidation? 31 Conclusion  Thank patient and hand hygiene  Summarise history and examination findings  Important positives and negatives  Practise with all patients and demonstrate this in OSCE Learning Outcomes  To demonstrate an understanding of the process of respiratory examination  To detect signs of respiratory pathology on clinical examination  To relate clinical signs to underlying pathology  Use history & examination findings to direct appropriate treatment / investigations