Physical Diagnosis of the Respiratory System

Symptom

• Complaints as reported by the patient

• Subjective

• Something that comes form the patient and it is up to us to believe it or not

  • the amount of experience will help us determine whether patient is telling the truth or not

Sign

• Findings by the medical professional

• Objective

• Established by using a standardized test

• Ex. fever - inc temp

Tidal Volume

amount of air a person is able to inhale and exhale at rest

• 500 ml

Inspiratory Reserve Volume

• Amount of air a person can maximally inspire at the end of a normal inspiration

• 1,900 mL to 3,300 mL

Expiratory Reserve Volume

Amount of air a person exhale some more maximally at the end of anormal expiration

700 mL and 1,200 mL

Vital Capacity

• IRV + TV + ERV

• Amount of air that can come in and could get out of a person’s lungs

• 3-5L

Residual Volume

Air that always stays in the lungs at the end of the expiratory reserve volume

1-1.5L

Total Lung Capacity

• VC + RV

• ~6L

Pattern of Breathing - Eupnea

• Normal, regular and comfortable at a rate of 12-20 cpm

• The younger the patient is, the faster the respiratory rate they would have

• Babies will be breathing faster than an adult

• Older people will be breathing slower

Pattern of Breathing - Tachypnea

• >20 cpm

• Can range from normal conditions to abnormal conditions

• Causes:

  • Infection

  • Acidosis

  • Hypoxemia

  • Heart Failure

Tachypnea - Infection

Infection causes faster metabolism → need to burn more/ need energy in the face of infection → so pulmonary system also compensates because body needs more oxygen → thus ↑ respiratory rate

Tachypnea - Acidosis

• High levels of acid present in the blood

• Acidosis → produces a lot of carbonic acid (one major form of acid) and if not removed will cause injury to the body → so respiratory system works hard by eliminating a lot of CO2 which is a by product of metabolizing carbonic acid and is blown off as CO2

Tachypnea - Hypoxemia

Low levels of O2 in the blood

Tachypnea - Heart Failure

• Heart can’t pump blood well and floods the pulmonary system

• Left side of the heart fails to pump → damming of blood in left ventricle → damming in left atrium → blood and fluid will go back upstream to pulmonary bed causing it to be flooded → low oxygenation → compromised O2 and CO2 exchange (in the capillary beds) → hypoxemia → difficulty breathing → ↑ respiratory rate (tachypnea)

Breathing Pattern - Bradypnea

• <12 cpm, slow

• Causes: hypothyroidism, electrolyte imbalances (sodium, potassium), drugs, obesity

• Thyroid gland releases thyroid hormones which interact with many body processes including respiration,

• Low levels = slow metabolism which can also affect breathing pattern

• Drugs such as anesthetic drugs/ pain reliever slow down the heart

• Sign of poor prognosis

Breathing Pattern - Hyperpnea

• Hyperventilation, deep breathing

• Form of tachypnea

• >20 cpm

• Causes: neurologic, psychiatric, metabolic, infection, stroke, tumor

• Psychiatric - some patients overexaggerate (TIA)

• Deeper than tachypnea; may observe labor breathing

Breathing Pattern - Sighing

• Frequently interspersed

• Deeper breath

• Can happen in between normal breaths

• Frequent sighs may suggest hyperventilation syndrome - (common cause of dyspnea & dizziness)

• Occasional sighs are normal

Breathing Pattern - Air Tapping

• increasing difficulty in getting breath out

• Causes: asthma, chronic obstructive pulmonary disease (COPD)

• Asthma: no problem in air entry, problem is found in expiration of air; asthmatic patients have bigger lungs than normal people

• Chronic Asthma - you can observe that their chest is bigger than normal individuals d/t air trapping

Breahting Pattern - Cheynes-Stokes

• Varying periods of increasing depth interspersed w/ apnea (not breathing)

• Apnea in between of increasing depths of breathing

• “Parang naghihingalo”

• More abnormal breathing; more serious pattern of breathing

• Commonly seen in ICU & in pts who are dying

• Causes: Obesity, Heart failure, Stroke, Brain tumor, TBI

• Medical emergency. Call MD immediately.

• Normal in children & older adults during sleep

Breahting Pattern - Kussmaul

• Rapid (tachypnic), deep, labored

• Can also present with intercostal retractions (from video of pt c diabetic ketoacidosis)

• Ketoacidosis - specific smell of ketones; d/t too much rigor in the body → poor sourcing of fuel leads to the body sourcing from ketones, with acid becoming a byproduct

• Patients with poorly controlled rigor can go into ketoacidosis ● Causes: acidosis, renal failure

• An effort to blow off a lot of acids (CO2) in the body

Breahting Pattern - Biot

• Irregularly interspersed periods of apnea in a disorganized sequence of breaths

• Causes: trauma, stroke, damage or pressure to medulla oblongata

• Medulla oblongata: where the control of respiration is located

• Similarity with Cheyne-stokes: there’s an apnea in between

• Has equal depths in the breathing pattern compared to Cheyne-stokes; depth is not increasing

Breathing Pattern - Ataxic

• Significant disorganization w/ irregular & varying depths of respiration

• Indicates poor prognosis

• Occasionally interchanged w/ biot; difference is there is more irregularity & depth is varying, and has no apnea

• Worse than biot

• Causes: damage to medulla oblongata (center for respiration; brain infection)

Influences on the Rate and Depth of Breathing: Increases

• Acidosis

• CNS Lesions (pons)

• Anxiety

• Aspirin poisoning

• Hypoxemia

• Pain

Influences on the Rate and Depth of Breathing: Decreases

1. Alkalosis

2. CNS Lesions (cerebrum-volitional breathing)

3. Myasthenia Gravis

4. Narcotic overdose (sedatives)

5. Obesity

Questions to ask pt (in order to come up with the right diagnosis or to be able to assess at what intensity the exercise should be given)

1. Is it present even when the patient is resting?

2. How much walking? On a level surface? Up stairs?

3. Is it necessary to stop and rest when climbing stairs?

4. What other activities precipitate it? What level of physical demand?

Orthopnea

• SOB that begins or increases when the pt lies down; gets the feeling of being drowned

• Quantified by the number of pillows needed to lie down comfortably (more venous return)

• 4-pillow orthopnea: need 4 pillows for comfort

• In upright position, there is less venous return to the heart as compared to a lying position wherein gravity is eliminated thus more blood return to the heart.

• Lying position will require the heart to work more. Thus, the heart of pts with congestive heart failure will have more difficulty in pumping the blood

• Heart failure: pulmonary edema, congestive heart failure ● Pts will be more comfortable in the upright position

• The blood that cannot be pumped by the system will just upstream to the pulmonary bed resulting into orthopnea.

How is Orthopnea quantified?

Quantified by the number of pillows needed to lie down comfortably (more venous return)

True/False: Orthopnea is worse compared to paroxysmal nocturnal dyspnea

True

Paroxysmal Nocturnal Dyspnea

• A sudden onset of shortness of breath after a period of recumbency ■ Sitting upright is helpful

• Does NOT happen immediately after assuming the supine position. Happens 3-4 hrs (sometimes 5 hrs) after assuming the recumbent position. The heart eventually gets tired from the ↑ venous return when the pt assumes a supine position.

Paroxysmal Nocturnal Dyspnea: Mechanism & Sx

• When the heart gets tired, it would rest/ “fail” resulting in an upstream of blood on the left ventricle to the lungs.

• Implies the heart is kind of weak but not as weak as overt heart failure.

• Pt would wake up in the middle of the night and describes experiencing a “feeling of drowning”

• Assuming the upright position helps in alleviating the sx and pt can go back to sleep afterward

• Usually occurs once or twice a night

Platypnea

SOB that begins or increases when the pt is upright

Platypnea - Cardiac Defects

• Cardiac defects, ie: ASD (atrial septal defect) with right-to-left shunt

• In utero, there's an opening between the two atria, but would close when the baby is born d/t the pressure outside prompting the closure of the foramen ovale.

• When the foramen ovale does not close, it results in atrial septal defect. Since the pressure on the left atrium is greater than the right atrium, the flow of blood will be from the left atrium to the right atrium. Overtime, because there is an ↑ of blood flowing from left to right, the pressure on the right side would exceed the left making it abnormal (process is called eisenmengerization).

• Normal Shunt: Left-to-right

• The right-to-left shunt would cause the SOB in the upright position

Platypnea - Worsening VQ Mismatch

Mismatch between ventilation and perfusion

Trepopnea

• SOB that is pronounced on side lying

• Due to a unilateral diseased lung

• E.g. Dyspnea occurs more when lying on the side of the normal lung since these structures are being compressed.

• Collapsed L lung and R sidelying = trepopnea

10 Ps of Dyspnea of Rapid Onset

Pneumonia

Pericardial Tamponade

Pneumothorax

Pump Failure

Pulmonary Constriction

Peak Seekers

Peanut

Psychogenic

Poisons

Pulmonary Embolus

10 Ps of Dyspnea - Pericardial Tamponade

• Excessive fluid in the pericardial sac 50mL fluid accumulated in the pericardial space suffocates heart & prevents it from pumping well

10 Ps of Dyspnea - Pneumothorax

hole in air sac, air stays in the pleural cavity compressing on the lung parenchyma resulting to dyspnea, can lead to death in an instant

10 Ps of Dyspnea - Pump Failure

blood / fluid will get dammed up in the pulmonary bed

*In patients with CAV, post-bypass, post-angioplasty, ischemic cardiomyopathy, they might go into rapid onset dyspnea bc of excessive exercise/having another heart attac

10 Ps of Dyspnea - Peak seekers

(High altitudes) diff in breathing because body is not accustomed to high altitudes (thinner air / levels of O2

10 Ps of Dyspnea - Peanuts

Foreign body e.g. small objects lodged / stuck in the airway

Cough

• Common symptom of a respiratory problem

• Causes may be related to localized or more general insults at any point of the respiratory tract.

  • is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi.

• May be voluntary or reflexive response to an irritant

Cough can signal ____ sided heart failure

left

Cough - Sequence of events

1. Usually preceded by a deep inspiration closure of glottis

• It is important to close the glottis for the air to be maintained inside below the level of the glottis down to the pulmonary/airway/air sacs

2. Contraction of chest, abdominal and pelvic muscles sudden spasmodic expiration (forces open the closed glottis; coughing out all the things that have been irritating the airway)

• In the elderly or in patients who have difficulty in controlling or weak pelvic muscles, they involuntarily urinate when they cough.

• Can do Kegel exercises to strengthen pelvic muscles

3. Air and secretion are exhaled

Sputum

• Generally associated with cough

• In more than small amounts and with any degree of consistency always suggests the presence of disease

• Sputum characteristics may give a clue to some causes of sputum

• The phlegm by itself or the sputum that sticks along the walls of the airway will cause irritation thereby initiating the cough reflex.

• Cannot expel sputum without coughing.

• Ask in a discreet way as this may be a social stigma

Hemoptysis

• can arise from anywhere in the respiratory tract; from the glottis to the alveolus.

• commonly results from infection, malignancy, or vascular disease; however, the differential for bleeding from the respiratory tree is varied and broad

Sputum - Bacterial infection

• Yellow, green, rust (blood mixed w/ yellow sputum), clear, or transparent; purulent (pus); blood streaked; mucoid (thick), viscid (thicker)

• clear/transparent - not yet prescribed with antibiotics in a patient with respiratory tract infection caused by bacteria, defer therapy as it will aggravate the pt’s condition. Wait for doctor’s clearance before continuing PT rehab.

Sputum - Viral Infection

mucoid, viscid; blood streaked (not common; possible that airways are wounded d/t continuous coughing); not too much hue

Sputum - Chronic Infectious Disease

Could be yellow or any color. All of the above; particularly abundant in the early morning; slight, intermittent, blood streaking; occasionally, large amounts of blood

Sputum - Carcinoma

slight, persistent blood streaking

Sputum - Infarction

• Blood clotted; When large amounts of blood, pt should be brought to the ER already, as pt may die anytime d/t blood loss or obstruction in the airways

Sputum - Tuberculous Cavity

Large amount of blood

Breath Smells - Sweet, fruity

Diabetic ketoacidosis (c loss of sensorium; ketones - sweet smelling; loss of consciousness/ consciousness is waning); starvation ketosis

Breath Smells - Fishy, stale

Uremia (acute/chronic renal failure, too much toxic in blood, urea nitrogen, creatinine in the blood)

Breath Smell - Ammonia-like

Uremia

If noticed before PT session, defer therapy because the patient might not carry on with the exercises

Breath Smells - Musty fish

Fetor hepaticus: hepatic failure, portal vein thrombosis, portocaval shunts

Breath Smells - Foul, feculent

Intestinal obstruction, diverticulum (feces reroutes towards mouth)

Breath Smell - Foul, prutrid

Nasal/sinus pathology: infection, foreign body (common in pedia), cancer; respiratory infections: emphysema, lung abscess, bronchiectasis

Breath Smell - Halitosis (type of ulcer caused by bacteria

Tonsillitis, gingivitis, respiratory infections, vincent angina, gastroesophageal reflux, PUD (peptic ulcer disease, H. Pylori

Breath Smell - Cinnamon

Pulmonary tuberculosis

Physical Examination - Position

• In the tripod position, there is an exchange of O2 and CO2 in the pulmonary bed

• This alone can tell you that the patient is in respiratory distress

Physical Examination - Color

• Cyanotic, bluish discoloration, pale

• Hypoxemia

Physical Examination - Mental Status

• Is the patient awake?

• Alert, enthusiastic

• Level of oxygen can always affect the level of mentation

• Ex: If Pt is hypoxemic, the brain goes hungry so the sensorium can actually deteriorate

Physical Examination - Ability to speak

• Can Pt speak in phrases? Full sentence?

• Can belt out into songs

Physical Examination - Respiratory Effort

• Is Pt speaking c so much effort?

• Is it just a breeze? (To speak)

Physical Examination - Thoracic Contour

• Chest will not be absolutely symmetric

• Normally wider than it is deep

• AP < transverse diameter ○ Should NOT be > 0.70 - 0.75

• AP diameter increases c age

  • Up to 0.9

• Upon checking the thoracic cage, you can assess whether Pt is a:

• Barrel Chest (malapad)

  • Sign of air trapping

  • Chronic asthma

  • Emphysema

  • Cystic fibrosis

Pectus Excavatum

• Now, if it’s not too deep it won’t render anything abnormal OR make Pt symptomatic it if doesn’t really compress the lungs or the heart

• Compression of the heart & great vessels may cause murmurs

Pectus Carinatum

• Doesn’t really impact negatively on the heart or the lungs UNLESS associated with some inborn metabolic derangement or any bony abnormalities

• Sign that this may be part of some syndrome, but not necessarily compromises the heart and lungs

Kyphosis

• Definitely compromises heart & lungs

• Compresses and limits the airways

Unequal chest expansion and respiratory compromise caused by:

• A collapsed lung & limitation of expansion

  • d/t fibrosis, muscular contracture, jt. mob problems, etc.

• If there is UNEQUAL expansion, you want to observe the breasts (do not oggle if female)

  • Observe the collar or movement of the dress or shirt; collapsed lung on the lagging side

Etiology of unequal chest expansion

• Extrapleural air: air is now in the pleural cavity compressing normal lungs

• Fluid: also limits expansion

• Mass (or Tumor)

Retractions suggest an?

obstruction to inspiration at any point in the respiratory tract

Retractions

• Intrapleural pressure becomes increasingly negative degree and level of retraction depend on the extent and level of obstruction

• Mechanism: Acts like a vacuum effect on the thorax

  • Ex: You bought a cup of sago’t gulaman. As you sip from a straw, you can’t sip further as it gets blocked

  • Your cheeks become the vacuum

• Medical emergency. Bring pt immediately to the ER

Signs of Upper Airway Obstruction

1. Inspiratory Stridor

2. Hoarse cough or cry or barking cough

3. Alar flaring

4. Retraction at the suprasternal notch

5. Cyanosis

Signs of Upper Airway Obstruction - Inspiratory Strider

Expiratory is severe; audible even without steth

Signs of Upper Airway Obstruction - Hoarse cough or cry or barking cough

• “Umiiyak na hindi basa”

• Like a dog barking

Signs of Upper Airway Obstruction - Alar flaring

Sign of air hunger

Signs of Upper Airway Obstruction - Retraction at the suprasternal notch

Could tell level of obstruction

Signs of Upper Airway Obstruction - Cyanosis

signs of low levels of oxygen

Signs of Supraglottic Obstruction

• Stridor tends to be quieter

  • Because the obstruction is not full

• Muffling voice (“hot potato in mouth”)

• Dysphagia

• No cough

  • Because you’re not irritating the most irritating part of the airways

• Awkward position of head and neck to preserve the airway

  • Looking for that position to establish a good airway (air can come in better)

Signs of Infraglottic Obstruction

• Stridor tends to be louder, rasping

• Hoarse voice

• Swallowing not affected

• Cough is harsh, barking

• Head positioning is not a factor

  • Because no matter the position of the head, pt will still have difficulty breathing since the obstruction is infraglottic, which is more difficult to attend to

Peripheral Signs of Airway Obstruction

• Cyanosis

• Pursing

• Clubbing

• Alar flaring

Peripheral Signs of Airway Obstruction - Cyanosis

• lips, nails

• Depending on the severity, when a pt becomes cyanotic, cyanosis of the lips and nails may simultaneously occur

• Not really evident on the onset

Peripheral Signs of Airway Obstruction - Pursing

Pursed lip breathing = something hot between mentis and lower lip and it seems like you are blowing that area

Peripheral Signs of Airway Obstruction - Clubbing

• finger nails

• Almost always indicates chronic hypoxemia

Peripheral Signs of Airway Obstruction - Alar flaring

• air hunger, esp. alveolar involvement

• Suggest cardiac or pulmonary difficulty

• Chronic pulmonary or cardiac problem

• In neonates: congenital cardiac or pulmonary defect

Auscultation - Breath sounds characteristics

• Intensity

• Pitch

• Quality

• Duration

Auscultation - Reminders

• As PTs, it’s okay if you’re listening for normal breath sounds but once you hear abnormal breath sounds, refer to a doctor

• Start from top to bottom

• Always compare both sides

  • It’s not checking all on one side first, but has to be contralateral side

• Listen to the chest anteriorly and laterally as the patient breathes with mouth open, and somewhat more deeply than normal.

• Listen to the breath sounds, noting their intensity and identifying any variations from normal vesicular breathing.

Breath sounds are usually louder in the ________ lung fields

upper anterior lung fields

________ breath sounds may be heard over the large airways, especially on the right

Bronchovesicular breath sounds

Normal Breath Sounds - Vesicular

• Heard over most of the lungs

• Most commonly auscultated breath sounds

• Low pitch

  • Rustling quality

• Soft and short expiration

  • Sounds become even softer during expiration

• More prominent in thin individuals or children

• Diminished in the overweight or muscular individuals

• Inspiratory time (I) is longer than Expiratory time (E)

  • Approx. I:E of 3:1

• Can be best heard in most areas of the lungs but are most prominently heard at the lung bases and periphery

Normal Breath Sounds - Bronchovesicular

• Heard over the main bronchus area and over upper right posterior lung field

• Breath sounds that you listened to over the bronchioles would be different if you listen to the breath sounds over the air sacs

When you place the stethoscopes over the lung parenchyma, over the air sacs → ______

Vesicular

There would be parts in the lungs that would be covered by the bronchioles and air sacs → ______ sound

Bronchovesicular

Bronchovesicular sounds characteristics

• Medium (mid-range) pitch and intensity

• Expiration equals inspiration

• Normal breath sounds

• Inspiratory time (I) is often equal to Expiratory time (E)

  • I:E of 1:1

• Intermediate/ mixture of:

  • Higher-pitched bronchial sounds

  • Low-pitched vesicular sounds

Bronchovesicular sounds can be heard hroughout the lung fields, but can be commonly heard in the __________

upper third of the chest

Bronchial / Tracheal (Tubular) sounds are heard only over _____

trachea

Bronchial / Tracheal (Tubular) sound characteristics

• High pitch

• Hollow or tubular sounds

  • Imagine blowing through a pipe

• Loud and long expirations, sometimes a bit longer than inspirations

True/False: Tubular sounds are quieter than vesicular sounds

False

Tubular sounds - If heard in the peripheral of the lungs, this could be a finding which is _______________________

abnormal and suspicious for pneumonia, pleural effusions or atelectasis

Vesicular - Duration, Intensity, Pitch, Locations

Duration	Inspiratory sounds > Expiratory sounds
Intensity of Expiration	Soft
Pitch of Expiration	Relatively low
Locations where heard normally	Over most of the lung