Respiratory Examination

alveoli

• tiny thin walled air sac at the end of bronchiole branches where gas exchange occurs

• millions of alveoli in each lung

lungs

• two lungs each side of the midline in the thoracic cavity

• the area between is the mediastinum occupied by the heart, great vessels, trachea and the and left bronchi

pleura

• closed sac of serous membrane that covers each lung and separates them from the other organs

• consists of two layers

  • visceral pleura - adhered to lung

  • parietal pleura - adhered to chest wall and diaphragm

  • two layers separated by thin film of serous fluid secreted by the membrane to prevent friction when breathing

which sides have which lobes

right side

• upper

• lower

• middle

left side

• upper

• lower

lung volume for males

6L

lung volume for females

4.2 L

standard respiration rate for adults

12-20/min

features of normal breathing

• effortless

• silent

• unconscious

what does SOCRATES stand for (pain)

Site

Onset

Character

Radiation

Associated factors

Time

Exacerbating

Reliving factors

Severity

common causes of a cough

• asthma - wheeze, often nocturnal, worse in mornings

• COPD - (smoker) usually produces sputum in mornings

• chronic heart failure

• interstitial lung disease

• drugs

important Q’s to ask about a cough

• time of cough - when is it worse?

• duration - acute less than 3 weeks, sub-acute 3-8 weeks, chronic more than 8 weeks

• relief with inhaler

• worse on lying down

• wakening

• sputum

• haemoptysis

what to ask about sputum

• colour

• amount

• taste or smell

• solid material

what to ask about haemoptysis

• amount, fresh in sputum

• coughed up

• vomited/ regurgitated

• from nasopharynx

serous sputum

appearance

• clear, watery, frothy pink

cause

• acute, pulmonary oedema

• alveolar cell cancer

mucoid sputum

• clear and grey - chronic bronchitis/COPD

• white and viscid - asthma

purulent sputum

• yellow - acute bronchopulmonary infection / asthma

• green - longer-standing infection. e.g. pneumonia, bronciectasis, cystic fibrosis, lung abscess

rusty sputum

• rusty red - pneumococcal pneumonia

dyspnoea

the sensation that unable to breath properly

orthopnoea

shortness of breath on lying, usually associated with left ventricular failure

paroxysmal nocturnal dyspnoea

wakes patient from sleep - usually LVF (in asthma - wheeziness often causes waking in early mornings)

MRC breathlessness scale

degree of breathlessness related to activitites

MRC Grade 1

not troubled by breathlessness except on strenuous exercise

MRC Grade 2

short of breath when hurrying on the level or walking up a slight hill

MRC Grade 3

walks slower than most people on the level, stops after a mile or so, or stops after 15 mins of walking at their own pace

MRC Grade 4

stops for breath after walking about 100yds or after a few minutes on level ground

MRC Grade 5

too breathless to leave the house or breathless when undressing

dysphonia

hoarseness caused by damage to larynx or the nerve to larynx

wheeze

high pitch whistling noise - air passing through narrowed airways

stridor

high pitched, harsh noise caused by obstruction of large airway - always needs investigation (unless viral croup)

IPPE

introduction

permisson

position

exposure

IPPA

inspection

palpation

percussion

auscultation

position for physical assessement

on bed 45 degrees

be on patients right side

what does exposure refer to

• remove shirt

• leave bra on

• need to get at ankles

inspection part 1 of IPPA

• discomfort pain

• breathlessness

• colour - cyanosis - blush discolouration = hypoxia

• audible breathing

• body mass

• confusion

inspection part 2 of IPPA

Hands:

• look for finger clubbing - potential COPD, lung cancer, cystic fibrosis, bronchiectasis, pulmonary fibrosis, mesothelioma, etc

• peripheral cyanosis

• temp

• tobacco staining

• radial pulse - check respiratory rate at the same time

• asterixis - CO2 retention

• tremor

eyes:

• conjuctival pallor

inspection part 3 of IPPA

mouth:

• central cyanosis under tongue

Neck:

• palpate for enlarged lymph nodes (from behind)

• submental

• Submandibular

• Anterior and posterior cervical

• Supraclavicular (including scalene nodes)

• Pre- and post- auricular

• Occipital

Inspect chest wall - anterior and posterior

• abnormalities e.g. asymmetry - big breath in and out

• breathing pattern and asymmetry of movement

• scale nodes

• surgical scars - lobectomy

Palpation of IPPA

• tracheal deviation

• chest expansion

  • check for symmetry when the patient is breathing

  • ask the patient to breath deeply, watch your thumbs move apart, this should be equal

  • feel the rib cage expand and contract

reduced expansion could mean:

• unilateral = consolidation, collapse

• bilateral = COPD, pulmonary fibrosis

percussion of IPPA

helps establish whether lungs are filled with air, fluid or solid material

• start with clavicles

• anterior wall - upper lobes

• posterior wall - lower lobes

• right lateral wall - middle lobe

• left lateral wall - lingula

normal percussion sound is resonant, long and loud, low pitched and hollow

• a solid area collapse will sound dull and thud-like

• pneumothorax will sound hyper-resonant, loud and lower pitched

auscultation in IPPA

• breathing deeply through open mouth

• assess breath sound quailty

• assess volume - reduced= collapsed/effusion

vocal resonance

• ask patient to say 111 or 99 while listening with stethoscope

• over consolidated lung (pneumonia) - clearly audible

• over effusion or collapsed lung - muffled

red flags signs for cough - non acute

• haemoptysis

• breathlessness

• fever

• chest pain

• weightloss

red flag signs for cough - serious acute illness - urgent admission

• respiratory rate more than 30 breaths per min

• tachycardia greater than 130 beats per min

• systolic bp less than 90

• diastolic bp less than 60

• oxygen saturation less than 92%

• peak expiratory flow rate less than 33% of predicted

• altered level of consciousness

• use of accessory muscles of respiration

suspected lung cancer 40+ - if unexplained

• persistent or recurrent chest infection

• finger clubbing

• supraclavicular lymphadenopathy or persistent cervical lymphadenopathy

• chest signs consistent with lung cancer

• thrombocytosis

suspected lung cancer 40+ - if 2 or more

• cough

• fatigue

• shortness of breath

• chest pain

• weight loss

• appetite loss