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Ishraq Elshamli Respiratory Unit Tripoli Medical Center.

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Presentation on theme: "Ishraq Elshamli Respiratory Unit Tripoli Medical Center."— Presentation transcript:

1 Ishraq Elshamli Respiratory Unit Tripoli Medical Center

2  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

3  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


5 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

6 2. SOB?  Using accessory muscles of respiration  Pursed lips  Prolonged expiratory phase ?COPD 3. Count Respiratory rate  Normal adult, breaths/min regular and unlabored.  Tachypnea is an adult RR> 24 breaths/min.  Bradypnea is an adult RR< 10 breaths/min.

7  Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it.  Wheeze  Stridor  Hoarseness


9 Tri-Pod Position : In patients with emphysema

10 Pink Puffer

11 Blue Bloater

12  Inhalers.  Oxygen.  CPAP machine (Obstructive sleep apnoea).  Sputum Pots.

13 Oximeter

14 Venturi mask : Provides controlled Oxygen therapy 24%, 28%, 35%, 60%

15 Ventolin Inhaler (mdi) Metered dose inhaler Foradil (Formetrol) Powder inhaler

16 Seretide diskhaler Pulmicort and Oxis turbohaler Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone), Ventolin (Salbutamol) Combivent(Salbutamol+ipratropium bromide)


18  Perfusion  Nicotine staining  Peripheral cyanosis  Bruising/ thin skin: steroid therapy  Clubbing - lung cancer, bronchiectasis, CF, lung abscess/empyema), pulmonary fibrosis, mesothelioma, (HPOA).

19  Tremor (fine ? Β 2 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







26  Pulse: palpate rate, rhythm, character.  Tachycardia: e.g. AF associated with pulmonary disease.  Tachycardia associated with beta 2 agonists (nebulised salbutamol)

27  Central cyanosis  Neck veins  Lymphadenopathy  Crepitus  Neck muscles  Indrawing  Pursed lips

28  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.





33  Improves ventilation.  Releases trapped air.  Keeps the airways open longer and decreases the work of breathing  Prolongs exhalation to slow the breathing rate Pursed lip breathing Relieves shortness of breath

34  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)




38 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation.

39  Always describe the chest in terms of anterior and posterior.  Describe the lungs as zones not lobes i.e. Upper/ middle/ lower zones

40 Posterior View Anterior View

41 Right Lateral View Left Lateral View

42 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.

43 3. Movements.  Equal symmetry or reduced on one side?  Respiratory effort, intercostal indrawing or use of accessory muscle.

44 Kyphosis: Causes the patient to bend forward. X-Ray shows curvature of the spine.

45 Pectus excavatum: Congenital posterior displacement of lower sternum. The x-ray shows a concave appearance of the lower sternum.

46 Barrel chest : In chronic lung hyperinflation (e.g.Asthma, COAD) Due to increased AP diameter of the chest.

47 Scoliosis Is an increased lateral curvature of the spine. (i.e. Like the shape of the Letter “S”).




51 1. Trachea: palpate for tracheal position midline or deviated Rt or Lt



54  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




58  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




62  Place left hand on chest wall, palm downwards with fingers separated  2 nd phalanx over area of intercostal space  Right middle finger strikes the 2nd phalanx producing hammer effect  Entire movement comes from wrist


64 Percussion Technique Compare like with like




68  Do not forget the apices of the lungs  Compare both sides 1. Impaired(dull)resonance obtained – Lung tissue is airless e.g. consolidation, collapse, fibrosis 2. Hyper resonant = pneumothorax/ COPD 3. Stony Dull = Pleural effusion




72  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

73  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.

74  Breath sounds  Added sounds  Vocal sounds (vocal resonance)

75 inspiration expiration inspirationexpiration inspiration Vesicular – Normal, Or Diminished localised or diffuse Bronchial Breathing Vesicular with prolonged expiration

76  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 1/3 rd expiration

77 Conduction limited by  Airflow limitation e.g. diffusely – asthma, emphysema localised – tumour, collapse  Something separating chest wall from lung e.g. effusion, fibrosis

78  “blowing” inspiratory & expiratory sounds  Expiratory phase as long as inspiration  Distinct pause between phases  High-pitched e.g. consolidation  Low-pitched e.g. fibrosis

79  Rhonchi (wheeze)  Crepitations (crackles)  Pleural sounds

80  Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema  Musical quality  High or low pitched  Usually expiratory  Expiration prolonged

81  Inspiratory noises, usually 2 nd half  Non-musical  Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration

82  Creaking noise  Movement of visceral pleura over parietal pleura  Surfaces roughened by exudate  2 separate phases at end inspiration and early expiration

83  Vocal resonance  Increased when voice sounds are louder and more distinct e.g. consolidation  Reduced when transmission impeded e.g. effusion, collapse

84  Type and amplitude of breath sounds  Type of added sounds and their location  Quality and amplitude of conducted sounds

85  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.

86  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.

87 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.

88 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.

89  If you can’t empty your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD.

90  At this stage say to the patient “Thank-you, you may sit back now” And to cover them up with the blanket

91  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

92 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

93 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

94 Pleural effusion

95 pneumothorax



98 1. A reasonable method. 2. She did commence examination of the chest from the posterior aspect. 3. 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.

99  Fibrosing alveolitis. What are other causes of bilateral basal crepitations : 1. Heart failure. 2. Brocnhiectasis. 3. Atypical pneumonia JVP sputum pots or inhalers

100 General Examination:  The patient was propped up in bed suggesting dyspnoea.  The face was flushed  flaring of the alae nasi  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. Causes of Dyspnea A pink puffer The patient had respiratory distress cor pulmonale or heart failure

101  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

102  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

103 COPD Respiratory failure Cor pulmonale

104  A methodical examination.  Evaluation of the findings at each step.  Makes diagnosis much easier.


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