Respiratory Examination

Patient should be undressed to the waist. Patient can be sitting in bed, over the edge of the bed or on a chair.

General Appearance
Dyspnoea at rest [shortness of breath]
Tachypnoea [rapid respiratory rate, should not exceed 14 breaths/min @ rest]
Are accessory muscles of respiration being used?
Character of cough – productive/dry                                                                              
Sputum production - Volume/purulent/blood
Stridor - rasping noise loudest on inspiration i.e. foreign body/tumour
Hoarseness [Listen to voice]

Hands
Clubbing
Nicotine Staining  
Wasting and weakness  
Flapping tremor/Asterixis
  
Face
Anaemia
Horners Syndrome  
Central Cyanosis
nasal polyps
Upper Respiratory tract infection  
Tooth Decay
Sinusitis
Facial plethora/oedema

Trachea
Is the trachea central or is it deviated from the midline? Explain to the patient that you are going to press gently on their neck and that it may be a little uncomfortable.
Use the forefinger of the right hand to palpate for the position of the trachea above and backwards from the suprasternal notch.
If displacement of trachea is present its edge rather than its middle will be palpated and a larger space will be present on one side than the other.
Causes of tracheal deviation
Towards the lesion

1.Upper lobe fibrosis
2.Upper lobe collapse
3.Pneumonectomy
Away from the lesion

1.Tension pneumothorax
2.Massive pleural effusion

Tracheal tug is present when the finger resting on the trachea moves inferiorly with each inspiration. This is a sign of gross overexpansion of the chest in emphysema.

The Chest

Inspection
Kyphoscoliosis
Pectus Excavatum
Pectus Carinatum
Barrel-shaped
Scars
Thoracoplasty
Radiotherapy
Subcutaneous emphysema
Prominent veins in superior vena cava obstruction
Chest movement

Palpation
1.  Chest expansion

• Measuring chest expansion provides information on a number of things.
• Is expansion equal on both sides?
• If the patient has a pneumothorax or an area of consolidation on one side, expansion will be decreased on that side.
• In patients with COPD, because their chest is hyperinflated, chest expansion is decreased overall.
• Expansion will also be decreased with diffuse pulmonary fibrosis.
• Place hands over upper anterior chest wall and get patient to take a deep breath in and out. Chest movement should be equal on both sides. This is checking anterior expansion. The hands can also be wrapped around the lower chest to measure outward expansion.
• Place hands on lower posterior chest wall with fingers extending around the sides of the chest. The thumbs are lifted slightly off the chest and should almost meet in the midline. On inspiration the thumbs should move symmetrically apart at least 5cm. This will assess lower lobe expansion.
• “Take a breath in, and let it all the way out please”. When they are in full expiration, place your hands over the lower ribs and stretch your thumbs out until they meet in the midline. “Take a deep breath in please” The distance your thumbs move apart is measured in centimetres

2.  Vocal fremitus

• Palpate the front and back of the chest with the palm of the hand in two comparable positions as the patient repeats 'ninety-nine'.
• Differences in vibration on the chest wall can be detected. The causes of change in vocal fremitus are the same as those for vocal resonance [checked as part of auscultation] e.g. consolidation. Over consolidated lung the sound/vibration is transmitted better.
• This sign may be difficult to interpret.

3.  Ribs

• Compress the chest wall anteroposteriorly and laterally.
• Localised pain suggests a fracture.

Percussion
Put left hand on the chest wall with fingers slightly separated and aligned with the ribs.
The middle finger is pressed firmly against the chest.
With the pad of the right middle finger strike firmly the middle phalanx of the middle finger of the left hand.
The percussing finger must be held slightly flexed and a loose swinging movement should come from the wrist.
Percussion of symmetrical areas of the anterior, posterior and axillary regions is necessary.

If the underlying structure contains air, the sound produced will be resonant.
If the underlying structure is solid, the sound produced will be dull.
As the lungs contain air, we expect to hear a resonant note throughout all lung fields.

Begin with percussion in the supraclavicular fossa over the apex of the lung.
Percuss the clavicles directly.
On percussion posteriorly, the scapulae should be moved out of the way by asking the patient to move their elbows forward. This rotates the scapulae anteriorly.

Dull – Percussion over solid structure i.e. consolidated area of lung.
Stony dull – Percussion over fluid-filled area i.e. pleural effusion.
Resonant – Percussion over normal lung.
Hyper-resonant – Percussion over hollow structures i.e. pneumothorax


Auscultation
Start using the bell of the stethoscope applied above the clavicles to listen to the lung apices.
Auscultate using the diaphragm over the anterior, lateral and posterior chest wall.
It is important to compare each side with the other and to listen over enough areas.
Ask the patient to “Breathe in and out through your mouth please”
Listen over the same areas you percussed, again comparing right & left sides at each level.
Listen for the quality and intensity of breath sounds and the presence of additional sounds.

Quality of breath sounds
1.  Vesicular breath sounds -Normal breath sounds are produced in the airways. There is no gap between inspiratory and expiratory sounds.
2.  Bronchial breath sounds - due to turbulence in the large airways. They have a hollow and blowing quality. Often a gap is present between inspiration and expiration.Heard over areas of

• consolidation [pneumonia]
• pleural effusion [above the fluid]
• collapsed lung [i.e. adjacent to a pleural effusion]

Intensity of breath sounds
1. Normal
2. Reduced
3. Causes of reduced intensity

COAD [especially emphysema]
Pneumothorax
Pleural effusion
Pneumonectomy
Pulmonary fibrosis
  
Added sounds  
1.  Wheeze - may be heard on inspiration or expiration or both.

• They imply significant airway narrowing.
• They tend to be louder on expiration.
• An inspiratory wheeze implies severe airway narrowing.
• Usually the result of acute [asthma] or chronic [COAD]
• Airflow limitation may be due to –

• Bronchial spasm
• Mucosal oedema
• Excessive secretions

2.  Crackles/Crepitations
Crackles [crepitations] are probably the result of small  peripheral airways collapsing on expiration.

• Fine Crackles – similar to hair rubbed between the fingers i.e. pulmonary fibrosis
• Medium Crackles – i.e. LVF
• Coarse Crackles – Characteristic of pools of retained secretions and have an unpleasant gurgling quality.They tend to change with coughing. I.e. bronchiectasis/pneumonia

3.  Pleural rub - Due to thickened, roughened pleural surfaces rubbing together as the lungs expand and contract - grating sound.I.e. Pulmonary infarction/pneumonia

4.  Vocal resonance
Auscultating while a patient speaks gives further information about the lungs ability to transmit sounds.
Ask the patient to repeat 'ninety-nine' and listen over each part of the chest.
Over consolidated lung the numbers are clearly audible while over normal lung the sound is muffled.

• Whispering pectoriloquy- Vocal resonance is increased to such an extent that whispered speech is distinctly heard. Ask the patient to whisper 'ninety-nine' and listen over each part of the chest.
• Aegophony- Consolidated lung tends to transmit high-pitched sounds so that speech heard through the stethoscope takes on a bleating quality. When a patient says 'e'[bee] it sounds like 'a' [bay]. Listen over each part of the chest as the patient repeats ‘bee’, ‘bee’, ‘bee’

ADDITIONAL INFORMATION

LOUD P2 -If loud pulmonary component to 2nd heart sound [P2] heard in second left intercostal space pulmonary hypertension should be suspected.
Pulmonary hypertensive heart disease [cor pulmonale] may be due     to:

• COAD
• Pulmonary fibrosis
• Pulmonary thromboembolism

PEMBERTONS SIGN – occurs in superior vena cava obstruction.

• Raise arms over head
• Facial plethora [redness]
• Inspiratory stridor
• Non pulsatile elevation of JVP

ABDOMEN
Enlarged liver due to secondary deposits in cases of lung cancer

FEET

• Oedema [right heart failure]
• DVT