Respiratory Examination

Respiratory ExaminationDr Will RickettsClinical Teaching Fellow, Barts Health NHS TrustHonorary Lecturer, QMULthanks toRuth Taylorthe order...IntroductionInspectionHandsArmsFaceNeckCervical Lymph NodesThe ChestObservePalpate PercussAuscultateCompleting the examination

Introduction WIPERWASH YOUR HANDSIntroduce yourselfPosition the patient at 45Expose the patient (chest exposed)Retreat.the orderIntroductionINSPECTIONHandsArmsFaceNeckCervical Lymph NodesThe ChestObservePalpatePercussAuscultateCompleting the examination

inspectionGeneral inspection from the end of bedLook around bed for:Oxygen masksNebulisersInhalersSputum potsMedicationsSats monitor

Inspection (2)Well/UnwellBreathing at rest Comfortable/DyspnoeaAdded Sounds:Cough WheezeStridor Scars Chest Shape Chest Movements Asymmetrical Chest ExpansionAccessory Muscle useSub-Costal/Inter-Costal RecessionPeripheral OedemaPeripheral Cyanosis

Whats this?

Lateral Thoracotomy ScarInspection (3)

Pectus ExcavatumPectus Carinatum

Barrel ChestInspection (4)

Peripheral OedemaPeripheral CyanosisThe order.IntroductionInspectionHANDSArmsFaceNeckCervical Lymph NodesThe ChestObservePalpate PercussAuscultate Completing the examination

Hands OBSERVE Peripheral CyanosisBlue nail bedsTar StainsClubbing (ABCDEF)Asbestosis/AbscessBronchiectasisBronchial CarcinomaCystic FibrosisDecreased O2 (hypoxia)EmpyemaFibrosisClubbing

Hands OBSERVE (2)Additional Movements?Resting tremor-agonist useCO2 Retention Flap

Hands PALPATERadial pulseRateRhythmCharacter Bounding = CO2 RetentionCheck Respiratory Rate at same time (whilst patient distracted by pulse check)Normal 12-20 bpmTemperature change (warm and well perfused?)

The orderIntroductionInspectionHandsARMSFaceNeckCervical Lymph NodesThe ChestObservePalpate PercussAuscultateCompleting the examination.

ArmsAsk for blood pressure

THE ORDERIntroductionInspectionHandsArmsFACENeckCervical Lymph NodesThe ChestObservePalpatePercussAuscultateCompleting the examination.

FACEEyesConjunctival PallorHorners SyndromePtosisMiosisAnhidrosisPossible apical Pancoasts TumourFacePlethoraCushingoid facies = Moon FaceMouthCentral Cyanosis

Horners SyndromeCushingoid FaciesAn Aside!

Little Jack Horner eSSATT in the cornerThere with his sunken eyeHis small pupil hidUnder his poor drooping lidWith the side of his face crisp and dry!

eSSATT = Encephalitis StrokeSyrinxAneurysm Carotid (or Dissection)TumourTrauma

Cushings SyndromeHorners SyndromeThe orderIntroductionInspectionHandsArmsFace NECKCervical Lymph NodesThe ChestObservePalpatePercussAuscultateCompleting the examination.

Neck Observe:JVP: Raised ?Cor PulmonaleRaised + Fixed?SVC ObstructionObvious lymph nodes +/- discharging sinuses Palpate:Trachea:PositionTug

THE ORDERIntroductionInspectionHandsArmsFace NeckCERVICAL LYMPH NODESThe ChestObservePalpatePercussAuscultate Completing the examination.

Neck palpate cervical lymph nodesPalpate all Lymph Node Groups Best done with Finger Tips from BehindPreauricularPosterior auricular OccipitalPosterior cervical chainSupraclavicularSubmandibularSubmental

CausesInfection TBMalignancy

The orderIntroductionInspectionHandsArmsFace NeckCervical Lymph NodesTHE CHESTObserve As abovePalpatePercussAuscultate Completing the examination

chest palpationApex Beat If Displaced consider:Pleural effusionPneumothoraxDifficult to feel in hyper expansionRight Ventricular HeaveCor pulmonaleChest ExpansionNormal >5cm

chest pattern of examinationAnterior Palpate Tactile Vocal Fremitus (TVF)PercussAuscultateAll performed in same order:Start anteriorly:Zig-Zag left/rightTop to bottomCoverUpperMiddle ZonesLowerCompare one side with otherRepeat Laterally & Posteriorly

chest pattern of examinationLateral

Again Compare Sideschest palpationtactile vocal fremitusPalpate with ulnar border of your handAsk patient to repeat Ninety-NineAssess all zones in zig-zag mannerNote ifIncreasedDecreasedAbsent

Where did this skill come from?

chest percussion Place spread fingers of one hand on chestRapidly tap and lift off with finger of otherAgain zig-zag to compare zones/sidesClavicles percussed directly

chest auscultation Ask the patient to breathe deeply through their mouth Auscultate in same pattern as TVF/PercussionListen for:Breath Sounds:Normal vesicular BronchialAbsentAdded soundsWheeze = ExpiratoryCrepitations = InspiratoryClears on Coughing?Pleural RubVocal Resonance Ninety-Nine (as per TVF) auscultate in same patternNo need to repeat if already performed TVFListen at your leisure!BREATH SOUNDSBreath sounds audibleThroughout inspirationFirst 1/3 ExpirationBreath sounds audibleFirst 2/3 InspirationLast 2/3 ExpirationVesicularBronchialInspirationExpirationInspirationExpirationSilenceSilenceSilencechest posteriorAsk patient to sit forwardPosition to pull scapulae forwardRepeat examination as per anterior:Same zig-zag patternPalpationExpansion (x2)TVFPercussionAuscultation+/- Vocal Resonance

Completing the examination......Examine:Sacral OedemaGently press lower backPeripheral Oedema Gently press feet/shins

Thank the patientOffer them help getting dressedWASH YOUR HANDS!!

possibleadditional testsBedsideO2 SaturationsTemperaturePeak flowBloods FBC, U&E, CRPCulturesArterial Blood Gas (ABG)Imaging CXRComplexSputum CultureSpirometry

tying it all togetherSignConsolidationPleural EffusionPneumothoraxFibrosisTracheaCentral?Displaced Away?Displaced Away?Displaced TowardsExpansion affected side affected side affected sidePercussionDull (not stony dull)Stony Dull over the fluidHyper resonance if largeVocal Fremitus affected side

Breath soundsBronchial/

/BronchialVocal ResonanceAdditional SoundsInspiratory crackles--Fine inspiratory crackles over affected lobesworked example copdInspection TachypnoeicPursed lip breathing with prolonged expirationBarrel chest (increased anterior-posterior diameter)Use of accessory musclesHands Tar stainingClubbingArms NormalFace Pink pufferNeckJVP Raised 2 cm

Pink Puffer Blue Bloaterworked example copd Cervical lymph nodesNo lymphadenopathyThe ChestPalpateReduced ExpansionHyper inflated chestTracheal TugTVF Normal Percuss Hyper resonant ThroughoutAuscultateDecreased breath soundsEarly inspiratory cracklesCompletion Mild peripheral oedema