Respiratory Therapy Exam Review

Clinical Assessment

Introduction

• Clinical assessments help physicians make decisions regarding initiation, changes, or discontinuation of therapy.
• Respiratory therapists (RTs) participate in clinical decision-making.
• Bedside assessment involves interviewing and examining the patient to identify signs and symptoms of the disease and evaluating treatment effects.
• Inexpensive and low-risk; helps identify the need for diagnostic tests.
• Key data sources: medical history and physical examination.
• Diagnosis identifies the nature and cause of illness.
• Differential diagnosis: signs/symptoms shared by many diseases.
• Signs: objective manifestations of illness.
• Symptoms: subjective experiences of illness.

Chart Review

• Includes demographic data, chief complaint (CC), history of present illness (HPI), past medical history, occupational/environmental history, family history, social and environmental history, review of systems, geographic exposure, activities of daily living, and advance directives.

Cardiopulmonary Symptoms

• Dyspnea: Subjective sensation of breathing discomfort.
  • Orthopnea: dyspnea in the reclining position (CHF).
  • Platypnea: dyspnea when upright.
• Breathlessness: Unpleasant urge to breathe; triggered by hypercapnia, acidosis, or hypoxemia.
• Assess dyspnea: ADLs that trigger it, exertion level, quality variations, and onset history.
• Note patient's ability to speak in full sentences.
• Psychogenic hyperventilation syndrome: Normal cardiopulmonary function with intense dyspnea and suffocation.
  *RTs should treat hyperventilation or dyspnea as pathogenic, checking vital signs, ABG, and ECG.

Cough

• Common, nonspecific symptom caused by airway irritation.
• Impaired in cardiopulmonary, neurologic, neuromuscular diseases, post-surgery, or trauma patients.
• Note if cough is dry/loose, productive/nonproductive, acute/chronic, and timing.
• Chronic cough lasts 8 weeks or longer.
• Causes of chronic cough: upper airway cough syndrome (UACS), asthma, gastroesophageal reflux, chronic bronchitis (smoking), ACE-1 cough, non-asthmatic eosinophilic bronchitis.

Sputum Production

• Phlegm from lower airways expectorated through mouth is sputum.
• Purulent sputum: contains pus cells.
• Fetid sputum: foul-smelling.
• Mucoid sputum: white/clear and thick (asthma).
• Changes in color, viscosity, or quantity may indicate infection.

Hemoptysis

• Coughing up blood or blood-streaked sputum.
  • Massive: >300 ml in 24 hours (bronchiectasis, lung abscess, tuberculosis).
  • Nonmassive: infection, tuberculosis, trauma, pulmonary embolism.
  • Differentiate from hematemesis (vomiting blood).

Chest Pain

• Pleuritic: lateral/posterior, sharp, increases with deep breathing (pneumonia, pulmonary embolism).
• Nonpleuritic: center of chest, may radiate, not affected by breathing (angina, gastroesophageal reflux).

Fever

• Temperature >38.3°C (101°F).
• Increases metabolic rate, oxygen consumption, and carbon dioxide production.
• Dangerous in chronic cardiopulmonary disease, may cause respiratory failure.

Pedal Edema

• Swelling of lower extremities, often due to heart failure.

  • Pitting edema: indentation after pressure.
  • Weeping edema: fluid leak at pressure point.

• Chronic hypoxemic lung disease leads to right heart failure (cor pulmonale).

Medical History Format

• Familiarizes clinician with patient’s condition.
• Review:
  • Chief complaint (CC)/history of present illness (HPI).
  • Past medical history (PMI): smoking history in pack-years.
  • Family/social/environmental history: genetic or occupational links.
  • Review of systems (ROS).
  • Advance directives.

Pack Years

• Packs smoked per day × number of years smoked.
• Example:
  • 1.5 packs x 20 years = 30 pack years
  • 0.75 packs x 20 years = 15 pack years
• Example: if a patient smoked \frac{1}{2} pack of cigarettes per day for 40 years. The pack-year smoking history will be:
  0.5 \times 40 = 20
  Patient has smoked 20 pack-year

Physical Examination

• Essential for evaluating patient's problem and effects of therapy.
• Four steps: inspection, palpation, percussion, auscultation.

General Appearance

• Assess level of consciousness, facial expression, anxiety, body positioning, and personal hygiene.

Level of Consciousness

• Sensorium: orientation to time, place, person, and situation (oriented x 4).
• Reflects brain oxygenation.
• Affected by poor cerebral blood flow (hypotension).

Vital Signs

• Vital Signs = RR, HR, BT, BP

Body Temperature

• Normal: 98.6 °F or 37.0 °C
• Increased: hyperthermia/hyperpyrexia (fever).
• The hypothalamus regulates heat (vasodilation and diaphoresis).
• Decreased: hypothermia (cold exposure).
• Measured at mouth, axilla, ear, or rectum (rectal is closest to core).

Heart Rate (HR)

• Tachycardia: HR > 100 bpm (fear, anxiety, low B/P, anemia, low PaO_2).
• Bradycardia: HR < 60 bpm (hypothermia, medications, TBI).
• Measure for full minute if irregular.
• Pulsus paradoxus vs. pulsus alternans.

Respiratory Rate (RR)

• Normal adult: 12 to 18/20 breaths per minute (bpm).
• Tachypnea: > 20 bpm.
• Bradypnea: < 10 bpm.
• Do not reveal assessment of RR to patient

Blood Pressure

• Systolic: 90 to 140 mmHg.
• Diastolic: 60 to 90 mmHg.
• Pulse pressure: 30 to 40 mmHg.
• Hypertension: > 140/90 mmHg.
• Hypotension: systolic < 90 mmHg or MAP < 65 mmHg (shock, hypovolemia).

Head and Neck Exam

• Nasal flaring: respiratory distress in infants.
• Cyanosis of oral mucosa: respiratory failure.
• Pursed-lip breathing: COPD, promotes lung emptying.
• Trachea midline, may shift with abnormalities.
• Jugular venous distention (JVD): heart failure (CHF), cor pulmonale.
• Enlarged lymph nodes: infection or malignancy.

Examination of the Thorax and Lungs

• Inspect: thoracic configuration, expansion, breathing pattern and effort.
• AP diameter < transverse diameter.
• Barrel chest: increased AP diameter (emphysema).
• Pectus carinatum: protrusion of sternum.
• Pectus excavatum: depression of sternum.
• Kyphosis: abnormal AP spinal curvature.
• Scoliosis: lateral spinal curvature.
• Kyphoscoliosis: combination, restrictive lung defect.
• Thoracic expansion: normal chest wall expands symmetrically.
• Diseases affecting both lungs cause bilateral reduction (neuromuscular disorders, COPD).
• Unilateral reduction: diseases affecting one lung.

Breathing Pattern and Effort

• Abnormal patterns: cardiopulmonary/chest wall diseases or neurologic disease.
• Increased WOB: narrowed airways, stiff lungs/chest wall.
• Retractions: inward sinking of chest wall during inspiration.
• Tracheal tugging: downward movement of thyroid cartilage.
• Rapid, shallow breathing; brief inspiration with prolonged exhalation.
• Apnea: no breathing (cardiac arrest, overdose, trauma).
• Agonal breathing: occasional breaths (cardiac arrest, stroke).
• Apneustic breathing: deep, gasping inspiration (damage to medulla/pons).
• Ataxic breathing: irregular pattern (damage to medulla).
• Asthmatic breathing: prolonged exhalation (airflow obstruction).
• Biot's respiration: rapid, shallow breaths with apnea (damage to medulla/pons).
• Cheyne-Stokes respiration: irregular breathing with periods of apnea (severe damage to cerebral hemispheres).
• Kussmaul breathing: deep and fast respirations (metabolic acidosis).
• Paradoxical breathing: abnormal abdominal or chest wall movement.
• Periodic breathing: rapid, deep breathing alternating with slow, shallow breathing

Chest Palpation

• Evaluate underlying structure and function.
• Increased vocal/tactile fremitus: pneumonia, atelectasis.
• Reduced vocal/tactile fremitus: emphysema, pneumothorax, pleural effusion.
• Bilateral reduction in chest expansion: neuromuscular disorders, COPD.
• Unilateral reduction: pneumonia or pneumothorax.
• Crepitus: air leaks into subcutaneous tissues (subcutaneous emphysema).

Chest Percussion

• Systematically test comparable areas.
• Decreased resonance: pneumonia or pleural effusion (consolidation).
• Increased resonance: emphysema or pneumothorax (air).

Chest Auscultation

• Technique: patient upright, relaxed, breathing deeply through open mouth. Stethoscope should be against the chest wall itself and avoid listening over clothing
• Auscultate all lobes (anterior, lateral, posterior) from bases to apexes.
• Lung sounds: breath sounds and adventitious lung sounds.

Auscultation of the Lungs

• Tracheal breath sounds: loud, turbulent flow over trachea.
• Bronchovesicular breath sounds: softer around sternum.
• Vesicular breath sounds: soft, low-pitched over lung parenchyma.

Breath sounds

• Tracheal (Bronchial) breath sounds: loud and high -pitched
• Bronchovesicular breath sounds: softer and slightly lower in pitch
• Vesicular breath sounds: muffled, low-pitched sound heard over lung parenchyma, represent attenuated (filtered) turbulent flow sounds from the larger airways

Mechanism and Significance of Lung Sounds

• Bronchial breath sounds: abnormal over peripheral lung, indicate consolidation.
• Diminished breath sounds: reduced sound intensity from shallow breathing or decreased transmission (COPD or asthma).

Adventitious Lung Sounds

• Discontinuous: crackles (intermittent crackling or bubbling).
• Continuous: wheezes (stridor over the upper airway).

Wheezes

• Narrowed airway walls, consistent with airway obstruction.
• Monophonic: one airway affected.
• Polyphonic: many airways involved.

Stridor

• Loud, high-pitched sound, indicates upper airway obstruction.
• Acute stridor: croup.
• Inspiratory stridor: narrowing above glottis.
• Expiratory stridor: narrowing of lower trachea.

Crackles

• Coarse crackles: airflow moves secretions, clears with cough or suctioning.
• Fine crackles: sudden opening of small airways late in inspiration (pulmonary fibrosis, atelectasis, pneumonia, pulmonary edema).

Pleural Friction Rub

• Creaking or grating sound with pleural inflammation.
• Similar to coarse crackles, not affected by coughing.
• Bronchophony: increased intensity of vocal resonance (lung tissue density).
• Egophony: long A sounds like long E.

Chest Auscultation - Summary Table

Cardiac Examination

• Chest wall overlying heart: precordium.
• Inspect, palpate, and auscultate for abnormalities.
• Point of maximal impulse (PMI): may be difficult to palpate in pulmonary hyperinflation (COPD).

Cardiac Auscultation

• Heart sounds created by valve closure.
  • S1: AV valves close.
  • S2: semilunar valves close.
  • S3: abnormal in adults, rapid filling of stiff left ventricle.
  • S4: atrial "kick" into noncompliant left ventricle.
  • S3 and S4: gallop rhythm.
• Murmur: abnormal sound from blood flowing through narrowed opening.
• Systolic murmurs: stenotic semilunar valves and incompetent AV valves.
• Diastolic murmurs: stenotic AV valves or incompetent semilunar valves.
• Diminished heart sounds can be attributed to : Pulmonary hyperinflation, pleural effusion, pneumonthorax and obesity
  • Also, due to poor ventricular concentration

Abdominal Exam

• Inspect and palpate for distention and tenderness.
• Enlarged liver (hepatomegaly): cor pulmonale.
• Abdominal paradox: diaphragm fatigue.
• Ascites: excess fluid in the abdominal cavity.

Examination of the Extremities

• Digital clubbing, cyanosis, pedal edema, capillary refill, peripheral skin temperature.

Digital Clubbing

• Seen in chronic conditions: congenital heart disease, bronchiectasis, cancers, interstitial lung diseases.

Cyanosis

• Digital cyanosis: poor perfusion, cool extremities.
• Peripheral cyanosis: poor perfusion, increased oxygen extraction.

Pedal Edema & Capillary refill

• Usually due to heart failure, the tissue leaves an ident when pressed firmly with a finger, this is known as "pitting edema"
• Normal color returns within 2 seconds
• Decreased cardiac output and poor digital perfusion can cause prolonged color return.

Clinical Laboratory Studies

• Complete Blood Count (CBC):
  • Red Blood Cell (RBC) Count, Hemoglobin, Hematocrit
  • White Blood Cell (WBC) Count, Platelet Count

Coagulation Studies

• Partial Thromboplastin Time (PTT): assesses intrinsic pathways (25-35 seconds).
• Prothrombin Time (PT): assesses extrinsic pathways (12-15 seconds).

Chemistry Results

• Sodium (Na+):
  • normal value: 136 – 145 mEq/L
  • responsible for osmotic pressure of extracellular fluid, cation of the extracellular fluid
  • Causes of Hypernatremia (High Na+):
    • Profuse Sweating
    • Profuse Diarrhea
    • Renal Disease
    • Prolonged Hyperpnea
• Potassium (K+):
  • normal value: 3.5 - 5 mEq/L
  • major cation occurring within the cells
  • Causes of Hypokalemia (Low K+)
    • Side effect of Albuterol
    • Decreased K+ Intake (Low Potassium Diet, Alcoholism) Increased Loss of Potassium
      • Gastrointestinal Loss
      • Renal Disease
      • Diuretics
    • Extracellular to Intracellular Shift of Potassium
      • Alkalosis and Increased Plasma Insulin
      • Diuretic Use