RESPIRATORY EXAMINATION

By

Augustin Gnanaprakasam

Introduction W - Wash your hands.I – Introduce yourself (full name and role). Greet the patient with their title and surname, and check you are using their preferred form of address.

P - Permission. Explain that you wish to perform a respiratory examination and obtain consent for the examination.

E - Expose the necessary parts of the patient. Ideally the patient should be undressed from the waist up taking care to ensure the patient is not cold or unnecessarily embarrassed.

R – Reposition the patient. In this examination the patient should be supine and reclined at 45 degrees

Peripheral ExaminationEnd of the Bed � The position of the patient .First look at the patient from the end of the bed for signs of breathlessnesss or distress. Those with extreme pulmonary dysfunction will often sit up-right. In cases of real distress, they will lean forward, resting their hands on their knees in what is known as the tri-pod position

It is also important to look at the surrounding environment for sputum pots, nebulisers, peak-flow meters, inhalers or oxygen tubing.

Breathing through pursed lips, often seen in cases of emphysema.

Ability to speak. At times, respiratory rates can be so high and/or �work of breathing so great that patients are unable to speak in complete sentences. If this occurs, note how many words they can speak (i.e. the fewer words per breath, the worse the problem!).

Hands Look at the hands for clubbing, tar staining and peripheral �cyanosis. Examine for tremor and a carbon dioxide retention flap.� Palpate the radial pulse to calculate heart rate. At this time also �assess respiratory rate and determine the pattern of breathing.

Face

Look at the patient’s eyes and face for signs of Horner’s syndrome or lupus pernio. Inspect the conjunctivae for anaemia.� Look at the lips and tongue for central �cyanosis Lie the patient at 45 degrees and �assess JVP. Palpate the cervical, supraclavicular �and axillary lymph nodes.

Examination of the chest

Examination of the chest

Examination of the chest

Inspection

1.look for chest deformity while you are examining the patient “anteriorly” or spine deformity “posteriorly”.a. Barrel chest: chest wall increased anterior-

posterior , Associated with emphysema and lung hyperinflation

b. Pectus excavatum: sternum sunken into the chestc. Pectus carinatum - sternum protruding from the chestd. Kyphosis: Causes the patient to be bent forward

e. Scoliosis: Condition where the spine is curved to either the left or right

2.look for skin ,scars , dilated vessels , respiratory distress signs Skin eruption e.g Herpes zoster Nodules (inflammatory, metastatic, lipoma,

neurofibroma…) Subcutaneous emphysema Purpuric spots, Vascular spiders, Bruises Prominent blood vessels (arterial in

coarctation of aorta and venous in SVC obstruction)

Scars (previous operation, trauma, sterneotomy)

Discharging sinuses Lesions of the breasts and enlargement of

axillary LNs

Signs of respiratory distress 1. Pursed-lip breathing - COPD (used to increase end expiratory pressure) . Accessory muscle use (scalene muscles) 2. Diaphragmatic paradox - the diaphragm moves opposite of the normal direction on inspiration . Any degree of asymmetry or asynchrony of chest expansion

3. Look for respiratory movement:In female - it is thoracoabdominal with chest predominant movement.In male - it is abdominothoracic movement

4. Use of accessory muscles of breathing:Intercostal indrawing , supraclavicular or intercostal retraction.

PALPATIONPalpation of Respiratory Movements1. Respiratory movements in the infraclavicular regions2.Respiratory movements at the costal margins3.Respiratory movements of the lower ribs posteriorly

PALPATIONSignifacance of reduced respiratory movements Unilateral reduction of chest wall movements Pleural effusion/empyema Pneumothorax Pulmonary collapse Pleural or parenchymatous pulmonary fibrosis

Bilateral reduction of chest wall movements: Bronchial asthma Emphysema Diffuse pulmonary fibrosis

TACTILE VOCAL FREMITUS

Increased TVFConsolidationCavitation Collapse with patent main bronchus Decreased TVFThick chest wallPleural effusion Collapse Pleural fibrosisPneumothorax

Percussion

Percussion :Anterior Chest Percussion: Posterior Chest

Auscultation:

“ The chest is ausculted with the diaphragm”

1. making sure to auscultate the apices and middle and lower lung fields posteriorly, laterally and anteriorly

2. Alternate and compare both sides at each site.

3. Listen to at least one complete respiratory cycle at each site

4. First listen with quiet respiration. If breath sounds are inaudible, then have him take deep breaths.

5. The lingula and right middle lobes can be examined while you are still standing behind the patient.

A few additional things worth noting.

1. Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.

2. Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.

3. If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their

IN SUMMARY;

3. EQUALITY OF ENTRY OF BREATHING SOUNDS IN BOTH SIDES

2. TYPE OF BREATHING

3. ADDED SOUNDS “CREPITATION,RHONCHI,PLEURAL RUB”

IN NORMAL LUNG The normal breath sounds heard over the lung are vesicular breathing. The vesicular breathing is heard over the lungs, lower pitched and

softer than bronchial breathing. Expiration is shorter (I > E) and there is no pause between inspiration and expiration.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position and dependent lung areas in decubitus position.

No adventitious sounds are heard. The breath sounds heard over the tracheobronchial tree are called

bronchial breathing. The only place where tracheobronchial trees are close to chest wall

without surrounding lung tissue are trachea, right sternoclavicular joints and posterior right intersca pular space. These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue and vesicular breathing is heard.

The bronchial breath sounds have a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration.

Voice Transmission Tests: are only used in special situations. All these tests become abnormal in consolidation to confirm bronchial breathing. They include Bronchophony Whispered Pectoriloquy Egophony   Voice sounds- Bronchophony1. Ask the patient to say "ninety-nine“ or 44 in arabic several times in a normal voice.2. Auscultate several symmetrical areas over each lung. 3. The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony

Whispered Pectoriloquy 1. Ask the patient to whisper "ninety-nine“ or 44 in arabic several times. 2. Auscultate several symmetrical areas over each lung. 3. You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy. Egophony1. Ask the patient to say "ee" continuously. 2. Auscultate several symmetrical areas over each lung. 3. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony. 4. Egophony (British: Aegophony) is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. 5. It is due to enhanced transmission of high-frequency noise across fluid, such as in abnormal lung tissue, with lower frequencies filtered out. It results in a high-pitched nasal or bleating quality in the affected person's voice

TAKEMY

BOW