Respiratory Examination Basheer Khassawneh, MD, FCCP Associate Professor Pulmonary and Critical Care and Sleep Medicine

Safety……. Wash hands Use mask and gown when asked Alcohol based gel Before and after Alcohol based gel Use mask and gown when asked

First Impression counts ……. Introduce yourself: Coat and ID Know the name of your patient Shake hands: cultural issues Tell patient what you intend to do and gain consent. Give a running commentary of what you are doing

Google … Physician

Exposure and Position Adequate exposure of chest Position Privacy Men: no shirt Women: cultural issues!!!! Position Anterior exam: supine Posterior: sitting upright

Observe surroundings Observe around the patient On the patient Oxygen Inhalers Sputum container On the patient Drips Oxygen masks Nebulizer CPAP

General inspection Colour - obvious cyanosis Does she/he look ill? Signs of respiratory distress? Muscle wasting - cachexia Presence of cough, wheezes, stridor,….

“Take two deep breaths please” General inspection From foot of the bed Ask the patient “Take two deep breaths please” Stridor Audible wheeze Chest movements, is it symmetrical?

Respiratory Rate Assess when patient is at rest and calm Try to not let the patient realize you are counting the respiration Check respiratory rate with your peripheral vision watching for each breath. Count for 30 seconds Normal respiration: 12 to 20 per minute

Patterns of Respiration Bradypnea: rate under 12: coma, medications, deep sleep Tachypnea: rate over 20: anxiety, heart or lung disease, pain Cheyne-Stokes: drugs, CNS damage, stroke Kussmaul: rapid, deep, labored: metabolic acidosis

“Can I have a look at your hands, please” Clubbing Peripheral cyanosis Nicotine stain on fingers Resting tremor Thin, paper like skin Muscle wasting Flapping tremor

Digital Clubbing Pulmonary Cardiovascular GI Bronchiectasis including cystic fibrosis Chronic lung infection Lung abscess Idiopathic lung fibrosis Lung cancer Cardiovascular Cyanotic congenital heart disease Infective endocarditis GI Cirrhosis of liver Inflammatory bowel disease

Digital Clubbing

Cyanosis A bluish or purplish tinge to the skin and mucous membranes Presence of  5 g/dL of deoxygenated hemoglobin in the capillaries Peripheral Fingernails and tips Central Mouth

Look at the face …. Horner’s syndrome Anemia Central cyanosis Eyes Horner’s syndrome Myosis Ptosis Anemia Lips/ tongue/mouth- Central cyanosis Pursed lip breathing

Examination of the Chest Surface anatomy Anterior examination Posterior examination Exam steps Inspection Palpation Percussion Auscultation

Surface Anatomy

SURFACE ANATOMY OF THE CHEST

SURFACE ANATOMY OF THE CHEST

Where are the Lungs?

WHERE ARE THE LUNGS? Lungs extend from T1 to T9 Posterior lung fields are mainly the lower lobes

Where are the lungs? Laterally the lungs extend to the 8TH rib All three lobes are accessible

Inspecting the chest Scars- Prominent veins previous chest drains Thoracotomy (look around back) Prominent veins Superior vena cava syndrome Chest shape Barrel chest increased AP diameter- hyperinflation Pigeon chest- pectus carinatum outward bowing of sternum and costal cartilages Funnel chest- pectus excavatum Kyphosis- forward curvature of spine Scoliosis – lateral curvature of spine

Palpation Trachea- is it central? Chest expansion Tactile vocal fremitus Superficial palpation

PALPATION –Tracheal Position It should be midline It may be lateral Pushed to other side Pneumothorax Pleural effusion Pulled to the same side Collapsed lung Post pneumonectomy

Palpation - Thoracic Expansion Placing the palms of the hands symmetrically on either side of the chest wall with the thumbs pointing towards the midline Ask the patient “Could you please take a deep breath in?” feel whether the fingers move apart symmetrically The thumbs should separate by at least 5cm

Tactile Vocal Fremitus Chest wall vibrations from speech (patient says "ninety-nine“ or اربع و اربعون) Compare sides, it is symmetric on both sides Decreased fremitus Pneumothorax Collapsed lung Pleural effusion ) Scarred, thickened pleura Increased fremitus In pneumonia

Tactile Fremitus

Percussion Note the resonance of percussion note Stony dull Dull Normal – resonant Hyper-resonant Tympanic Note the level of note change

Percussion

Auscultation Breathe in and out of mouth Breath sounds Added sounds Vesicular Bronchial Broncho-vesicular Added sounds Wheezes Crackles Pleural rubs Note where these are occurring Vocal resonance

AUSCULTATION Technique Diaphragm Vs. Bell !!! Move from side to side

Breath Sounds Vesicular Low pitched and soft Continuous from inspiration to expiration Inspiration > Expiration Heard over most of the lung (periphery) Sound of air moving in small airways and alveoli

Breath Sounds Bronchial Higher pitched Expiration > Inspiration Gap between inspiration and expiration Heard normal over the trachea Abnormal elsewhere Consolidation Above pleural effusion

Auscultation Breath sounds are softer/distant Air around the lung (pneumothorax) Fluid around the lung (pleural effusion) Obese or has pleural thickening or scarring Moving less air (severe chronic obstructive lung disease or asthma)

Auscultation Vocal resonance Whispered pectoriloquy Egophony Transmission of patient's voice The auditory equivalent of tactile fremitus Whispered pectoriloquy A whisper is clear to the stethoscope Egophony Patient says EE and stethoscope hears A Similar to increased tactile fremitus

Auscultation Crackles Inspiratory sound Water in the alveoli (heart failure) Pus in the alveoli (pneumonia) Scarring (pulmonary fibrosis)

Auscultation Wheezes High pitched Continuous whistles Usually in expiration Sign of airway obstruction Asthma,COPD, …

Auscultation Rhonchi Friction rub Low pitched, snore-like Heard in inspiration and expiration Originate in larger airways Friction rub Dry, leathery sound It is a sign of inflammation of the pleura

Reading list http://www.youtube.com/watch?v=iqpm3c4ys6U http://www.easyauscultation.com/lung-sounds