Transcript Slide 1
Ishraq Elshamli
Respiratory Unit
Tripoli Medical Center
Privacy : warm, well-lighted, quiet room.
Wash your hands
Introduce yourself to the patient.
Seek permission for the examination and
be polite to the patient.
“Stop me at any time if it becomes
uncomfortable or I cause you any
discomfort
While seated or standing, the patient should
be exposed to the waist OR uncovered
intermittently.
Teach the patient how to breathe deeply and
quietly, slowly inhaling and exhaling
through an open mouth
Stand back, to the right hand side of the
patient :
1. General appearance :
Thin, Pink puffer, cachexia.
Obese, blue bloater, cushinoid features
Cyanosis
Features of SVCO
2.
3.
SOB?
Using accessory muscles of respiration
Pursed lips
Prolonged expiratory phase ?COPD
Count Respiratory rate
Normal adult, 12 - 20 breaths/min regular and
unlabored.
Tachypnea is an adult RR> 24 breaths/min.
Bradypnea is an adult RR< 10 breaths/min.
Audible cough : is it dry/ productive. Is
there a sputum pot? If so, look in it.
Wheeze
Stridor
Hoarseness
Tri-Pod Position : In patients with emphysema
Pink Puffer
Blue Bloater
Inhalers.
Oxygen.
CPAP machine (Obstructive sleep apnoea).
Sputum Pots.
Oximeter
Venturi mask :
Provides controlled Oxygen therapy
24%, 28%, 35%, 60%
Ventolin Inhaler (mdi)
Metered dose inhaler
Foradil (Formetrol)
Powder inhaler
Pulmicort and Oxis turbohaler
Seretide diskhaler
Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone),
Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)
Perfusion
Nicotine staining
Peripheral cyanosis
Bruising/ thin skin: steroid therapy
Clubbing - lung cancer, bronchiectasis, CF,
lung abscess/empyema), pulmonary
fibrosis, mesothelioma, (HPOA).
Tremor (fine ? Β2 agonist)
Flapping tremor (CO2 retention) .
Other conditions: e.g. Yellow Nails/ RA hands/
Scleroderma/ Wasting of the intrinsic muscles of
the hands (cachexia/ pancoast tumour)
Pulse
Pulse: palpate rate, rhythm, character.
Tachycardia: e.g. AF associated with
pulmonary disease.
Tachycardia associated with beta 2 agonists
(nebulised salbutamol)
Central cyanosis
Neck veins
Lymphadenopathy
Crepitus
Neck muscles
Indrawing
Pursed lips
Horner’s Syndrome (MEAP! Myosis,
enophthalmos, anhydrosis, ptosis).
Central Cyanosis (4g of Hb has to be
deoxygenated).
Acneform eruptions associated with
immunosuppressive therapy.
Cushingoid appearance with long-term
steroid use .
Pursed lip breathing
Improves ventilation.
Releases trapped air.
Keeps the airways open
longer and decreases the
work of breathing
Prolongs exhalation to slow
the breathing rate
Relieves shortness of
breath
Position of the trachea
Lymph node enlargement (tuberculosis,
lymphoma, malignancy, sarcoidosis)
Scars (phrenic nerve crush for old TB)
Tracheostomy scarprevious ventilation in
COPD etc. Central line scars
Scar from LN biopsy
JVP - ? right sided heart failure (cor pulmonale
as a result of chronic lung disease)
1.
Inspection.
2.
Palpation.
3.
Percussion.
4.
Auscultation.
Always describe the chest in terms of
anterior and posterior.
Describe the lungs as zones not lobes
i.e. Upper/ middle/ lower zones
Anterior View
Posterior View
Left Lateral View
Right Lateral View
Inspection is performed to:
1. Scars : pneumonectomy ,lobectomy
Chest drains , thoracocentesis.
Radiation tattoo’s (previous radiotherapy).
2. Shape or Chest wall deformity – pectus
excavatum / carinatum(pigeon chested),
Barrel chest (Hyper-inflated), Kyphosis,
Scoliosis.
3. Resp rate, depth& Mode of breathing.
3.
Movements .
Equal symmetry or reduced on one side?
Respiratory effort, intercostal indrawing or
use of accessory muscle .
Kyphosis:
Causes the patient to bend forward. X-Ray shows curvature
of the spine.
Pectus excavatum:
Congenital posterior displacement of lower sternum.
The x-ray shows a concave appearance of the lower sternum.
Barrel chest :
In chronic lung hyperinflation (e.g.Asthma, COAD)
Due to increased AP diameter of the chest.
Scoliosis
Is an increased lateral curvature of the spine .
(i.e. Like the shape of the Letter “S”).
Trachea:
palpate for tracheal position midline or
deviated Rt or Lt
1.
Place your palms on the patient’s chest
with your thumbs parallel to each other
near the midline
OR lightly pinch the skin between your
thumbs
Ask the patient to take a deep breath ,
observe for bilateral expansion
Place the ulnar side of your hand on the
patient’s chest .
Instruct the patient to say “44” each time
they feel your hand on their back.
Comment on the tvf increased or decreased
Place left hand on chest wall, palm
downwards with fingers separated
2nd phalanx over area of intercostal space
Right middle finger strikes the 2nd phalanx
producing hammer effect
Entire movement comes from wrist
Percussion
•Technique
• Compare like with like
Do not forget the apices of the lungs
Compare both sides
Impaired(dull)resonance obtained –
Lung tissue is airless e.g. consolidation, collapse,
fibrosis
1.
2.
Hyper resonant = pneumothorax/ COPD
3.
Stony Dull = Pleural effusion
Diaphragm of stethoscope covers a larger
surface than the bell
Breath deeply with Mouth open
Systematic approach over several areas,
comparing both sides
listen to one complete respiration
Repeat asking patient to say “9,9,9” for vocal
resonance
Whispering pectoriloquy
The auscultatory assessment includes
(1) breath sounds audible or not .
(2) Character of breath sounds.
(3) Abnormal sounds or added sounds.
(4) Examination of the sounds produced by the
spoken voice.
Use a zigzag approach, comparing the finding at
Each point with the corresponding point on the
Opposite hemithorax.
Breath sounds
Added sounds
Vocal sounds (vocal resonance)
inspiration
expiration
Vesicular – Normal, Or Diminished
localised or diffuse
inspiration
expiration
Vesicular with prolonged expiration
inspiration
Bronchial Breathing
expiration
Vibrations of the vocal cords caused by
turbulent flow through the larynx
Transmitted along trachea, bronchi to chest
wall
Rustling quality
Inspiration continuous with expiration
Intensity increases during inspiration &
fades during first 1/3rd expiration
Conduction limited by
Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
Something separating chest wall from lung
e.g. effusion, fibrosis
“blowing” inspiratory & expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched e.g. consolidation
Low-pitched e.g. fibrosis
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds
Due to passage of air through narrowed
bronchus e.g. bronchospasm, mucosal
oedema
Musical quality
High or low pitched
Usually expiratory
Expiration prolonged
Inspiratory noises, usually 2nd half
Non-musical
Due to explosive reopening of peripheral
small airways during inspiration which have
become occluded during expiration
Creaking noise
Movement of visceral pleura over parietal
pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and
early expiration
Vocal resonance
Increased when voice sounds are louder and
more distinct e.g. consolidation
Reduced when transmission impeded e.g.
effusion, collapse
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds
With your stethoscope the over area of
possible pathology, have the patient whisper
the phrase ‘one-two-three’. Listen to hear if
the sound is distorted.
Confirm that a similar change is absent
over the identicallocation on the
contralateral chest.
With your stethoscope over the area of
possible pathology, have the patient vocalize
the vowel ‘EEEE’.Listen for the sound to be
distorted into the sound ‘AHHH’.
Confirm that a similar change is absent
over the identical location on the
contralateral chest.
1.
Reviewing the temperature and blood
pressure.
2.
Examine for features of cor pulmonale.
(Inspect the JVP / look for peripheral oedema
/ other signs of right heart failure).
3.
Check the patient’s peak flow and forced
expiratory time.
Instruct the patient to:
take in as deep breath in as deep as you can and
then hold it. Then, breathe out as forcefully and
as quickly as possible.
Or
blow as hard as you can until all the air has
emptied from your lungs.
If you can’t empty your lungs in 6 seconds,
this suggests a degree of obstruction i.e.
COPD.
At this stage say to the patient
“Thank-you, you may sit back now”
And to cover them up with the blanket
Breath sounds locally reduced or absent over pleural
effusion, thickened pleura, collapsed area
Breath sounds diffusely reduced in emphysema, asthma
Rhonchi heard in asthma, COPD
Crepitations may be widespread in COPD, LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy
Pleural effusion
reduced tactile vocal
fremitus
reduced chest expansion
stony dull
reduced air entry
no added sounds
reduced vocal resonance
Consolidation
increased tactile vocal
fremitus
reduced expansion
dull percussion
bronchial breathing
coarse creps
increased vocal resonance
whispering pectoriloquy
Pneumothorax
deviated trachea
reduced tactile vocal
fremitus
hyper-resonance
reduced air entry
reduced vocal
resonance
Collapse
deviated trachea
reduced tactile vocal
fremitus
dull percussion
reduced air entry
+/- creps
Pleural effusion
pneumothorax
EXAMPLE:
1.
2.
3.
A reasonable method.
She did commence examination of the
chest from the posterior aspect.
The findings:
The patient was breathless at rest.
Was using oxygen via nasal prongs.
There were no peripheral signs .
The chest was normal apart from bilateral
basal crepitations.
Fibrosing alveolitis.
What are other causes of bilateral basal
crepitations :
JVP
1.
Heart failure.
2.
Brocnhiectasis.
3.
Atypical pneumonia
sputum pots or inhalers
General Examination:
The patient was propped up in bed
Causes of Dyspnea
suggesting dyspnoea.
The face was flushed
A pink puffer
flaring of the alae nasi The patient had respiratory distress
O/E No clubbing but the peripheries were
warm with high volume pulse not collapsing
neck we noted a raised JVP almost to the ear
lobe with no predominant waveform .
cor pulmonale or heart failure
Barrel shaped .
There was little movement of the chest wall
with respiration being predominantly
abdominal.
Respiratory rate was 26 per minute.
The apex beat was difficult to palpate
Respiratory movements were equal on the
two sided vocal fremitus unremarkable
Percussion not showed increased resonance
with diminished cardiac and liver dullness
Breath sounds were vesicular
There were a few crepitations at both bases
but they were mostly mid-inspiratory and
cleared with coughing
Heart sounds were soft
COPD
Respiratory failure
Cor pulmonale
A methodical examination .
Evaluation of the findings at each step.
Makes diagnosis much easier.