Medical Education Without Limits!

Respiratory System Examination

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Intro (WIIPPPPE)

  • Wash your hands
  • Introduce yourself
  • Identity of patient – confirm
  • Permission (consent and explain examination)
  • Pain?
  • Position at 45°
  • Privacy
  • Expose chest fully

 

General Inspection

  • Surroundings
    • Monitoring:
      • pulse oximeter
      • ECG monitoring
    •  Treatments:
      • Oxygen therapy (method of delivery, rate, sats, humidified, venturi)
      • Inhalers
      • Blue (reliever, short-acting B2 agonist e.g. salbutamol)
      • Brown (preventer, corticosteroids e.g. beclometasone)
      • Spiriva (tiotropium bromide, COPD patients)
      • Nebulisers (driven by air or oxygen?)
      • Non-invasive ventilation
      • IV infusions
      • Chest drains
      • Creon (capsules for CF patients with exocrine pancreatic insufficiency)
    •  Paraphernalia:
      • Food and drink or supplements
      • Sputum pots
      • Cigarettes/ nicotine patches/ gum
  • Patient
    • Well or unwell?
    • Alert and orientated or drowsy and confused?
    • Comfortable at rest or in pain?
    • Body habitus?  Cachectic or obese?
    • Signs of respiratory distress:
      • Dyspnoea/ tachypnoea
      • Tripod posture
      • Use of accessory muscles
      • Pursed lip breathing
      • Flared nostrils, intercostal/ subcostal recession, tracheal tug (children)
    • Chest shape
    • Breathing pattern
    • Added breath sounds? Stridor, audible wheeze?
    • Colour? Pale and shocked or peripherally cyanosed?
    • Obvious scars
  • Ask patient to cough – dry or productive
Watch the Video on Examination of the Respiratory System

     

Hands

  • Inspect
    • Clubbing – perform Shamoroth’s window test and consider respiratory causes:
      • Abscess of lung
      • Bronchiectasis
      • Cancer of the lung (not SCLC)/ Cystic fibrosis
      • Empyema
      • Fibrosis
    • Cigarette tar staining (not nicotine!)
    • Peripheral cyanosis
    • Wasting of small muscles of hand
      • Especially dorsal interossei and thenar eminence
      • Can be caused by a C8/T1 lesion e.g. Pancoast’s tumour
    • Hand signs of rheumatological conditions or steroid use
  • Palpate:
    • Pulse
    • RR
      • Normally 12-16 breaths per minute
      • Component of CURB-65
    • CO2 retention flap (also look for fine salbutamol-induced tremor)

 

Arms

  • Signs of steroid use (thin skin, easy bruising)
  • Cannulae
  • Ask for BP (component of CURB-65)

 

Neck

  • JVP – respiratory causes of ↑JVP:
    • Tension pneumothorax
    • Severe acute asthma
    • PE
  • Carotid pulse (CO2 retention = bounding)
  • Tracheal deviation
    • Normal = central
    • Deviated away = tension pneumothorax, large pleural effusion
    • Deviated towards = lung collapse, pneumonectomy

 

Face

  • Facial swelling
  • SVC obstruction (usually due to bronchogenic carcinoma)
  • Smoker’s facies
  • Horner’s syndrome
    • Unilateral miosis, ptosis and anhidrosis
    • May be caused by Pancoast’s tumour
  • Conjunctival pallor (anaemia)
  • Blue lips- peripheral cyanosis
  • Mucous membranes (dehydration)
  • Tongue (bright red = CO poisoning)
  • Central cyanosis under tongue – respiratory causes:
    • Pneumothorax
    • PE
    • Pleural effusion
    • Pulmonary oedema
    • COPD
    • Acute severe asthma
    • Acute respiratory distress syndrome (ARDS)

 

Chest: anterior

  • Examine anterior chest as quickly and efficiently as possible as most signs will be best detected on the posterior chest
    • Inspect (ask patient to put hands on hips)
      • Chest wall deformity
        • Pectus excavatam (‘funnel chest’ e.g. Marfan’s syndrome)
        • Pectus carinatum (‘pigeon chest’ e.g. severe childhood asthma)
        • Harrison’s sulcus (severe childhood asthma)
        • Barrel chest (asthma, COPD)
      • Breathing pattern
        • Seesaw breathing (diaphragm in, abdomen out on inspiration; severe airway obstruction)
        • Fail chest/ paradoxical breathing (fracture of 2 or more ribs anteriorly and posteriorly)
        • Kussmaul breathing (DKA)
        • Cheynes-Stokes/periodic breathing (comatose patient)
      • Missing ribs
      • Scars
        • Thoracotomy – pneumonectomy or lobectomy
        • Thoracoplasty – rib removal (commonly old TB)
        • Small scars in axillae (previous chest drains)
      • Radiotherapy tattoos
    • Palpate
      • Apex beat (may be impalpable in COPD, pleural effusion)
      • RV heave (cor pulmonale)
      • Expansion:
        • Lateral: symmetry, >5cm increase
        • AP: symmetry
    • Percuss
      • At apices and 3 places on each side, alternating sides in an S shape, then axillae
    • Auscultate
      • Same places as percussion
      • Vocal resonance
        • If an area of dullness is found, vocal resonance can be used to distinguish between consolidation (increased) and effusion (decreased).
        • It is not necessary to also perform pectoriloquy or tactile vocal fremitus, but it is important to be aware of them.

 

Chest: posterior

  • It is often easier to detect pathology when examining the posterior chest so be thorough!
    • Inspect again
      • Scars
      • Radiotherapy tattoos
      • Deformity – particularly kyphosis or scoliosis
      • Breathing pattern
    • Palpate
      • Expansion- repeat lateral expansion
      • Lymph nodes
        • Cervical
        • Supraclavicular
      • Sacral oedema (cor pulmonale)
    • Percuss
      • Percuss the upper, middle and lower zones in an S shape
    • Auscultate
      • Same as percussion
      • Vocal resonance

Legs

  • Peripheral oedema
    • Cor pulmonale
  • Easy bruising
  • Calf swelling (DVT)
  • Erythema nodosum
    • Respiratory causes:
      • Viral/ streptococcal throat infections
      • Mycoplasma pneumoniae infections
      •  TB
      • Sarcoidosis

 

Closure

  • Thank patient
  • Patient comfortable?
  • Help getting dressed?
  • Wash hands
  • Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
    • Bedside investigations:
      • Look at obs chart and repeat set of obs (pulse, BP, SATs, temp.)
      • Measure peak flow
      • Inspect any sputum pots and send for MCS
    • Further investigations as needed:
      • Bloods
      • Lung function tests
      • CXR

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Categorised in: Medicine, Respiratory Medicine

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