1. Respiratory Assessment
Anne Dobbs

2. AIMS Review respiratory anatomy
Understand assessment of the respiratory system
Consider adjuncts to the respiratory assessment
Care of patient with respiratory conditions

3. Anatomy

4. History Taking Site Onset Characteristics Radiation Associations Time
Exacerbating / relieving factors
Severity
Past Medical History MJTHREADS Drug History Recreational drugs Immunisations Allergies Social History Family History

5. Specific questions? Weight loss Night sweats
Fatigue / malaise / lethargy
Sleeping pattern
Appetite
Fever
Itch / rash
Trauma
Lumps / bumps / masses
Unexplained falls
Sore throat
Cough
Sputum
Wheeze
Haemoptysis
Shortness of breath
Exercise tolerance

6. Red Flags Cough >3 weeks Persistent cough in a smoker Haemoptysis
Persistent hoarseness >3 weeks
Persistent sore throat
Persistent palpable neck lumps
Persistent unilateral enlarged tonsil
Difficulty completing sentences
Difficulty swallowing (particularly own saliva)
Shortness of breath
Pleuritic chest pain
Headache, photophobia and neck stiffness
Non-blanching rash

7. Warning!

8. Clinical Examination

9. Breathing Assessment GRIPPAS General assessment Respiratory Rate
Inspection
Palpation
Percussion
Auscultation
Saturations

10. General inspection Age:
Young patients – more likely asthma or cystic fibrosis (CF)
Older patients – more likely COPD/interstitial lung disease (ILD)/malignancy
Treatments or adjuncts around bed – O2 (ILD, COPD) / inhalers or nebulisers (asthma, COPD) /sputum pots (COPD, bronchiectasis)
Does patient look short of breath? – tripod position / nasal flaring / pursed lips / use of accessory muscles / intercostal muscle recession
Is the patient able to speak in full sentences?
Scars (more details in the close inspection of the thorax section below)
Cyanosis – bluish/purple discolouration – (<85% oxygen saturation) 
Chest wall – note any abnormalities or asymmetry – e.g. barrel chest (COPD)
Cachexia – very thin patient with muscle wasting  (malignancy, cystic fibrosis, COPD)
Cough:
Productive (bronchiectasis / COPD if older / CF if younger)
Dry (asthma if younger / ILD if older)
Wheeze (expiratory) – asthma / COPD / bronchiectasis
Stridor (inspiratory) – upper airway obstruction
Hands
Inspect the hands:
Tar staining on fingers (or nicotine patches on body)- smoker – increased risk of COPD / lung cancer
Clubbing –  lung cancer / interstitial lung disease / bronchiectasis
Peripheral cyanosis – bluish discolouration of nails – O2 saturations <85%
Features of rheumatological disease (e.g. joint swelling/tenderness) – rheumatological diseases (e.g. rheumatoid arthritis) can associated with pleural effusions and pulmonary fibrosis
Skin changes – bruising and thinning of the skin are associated with long term steroid use (ILD / asthma / COPD)
Assess temperature – ↓ temperature suggests  peripheral vasoconstriction / poor perfusion
Palpate pulse – rate and rhythm
Assess respiratory rate – normal adult range = breaths per minute
Pulsus paradoxus – pulse wave volume decreases with inspiration – asthma / COPD 
Fine tremor – can be a side effect of beta 2 agonist use (e.g. salbutamol)
Flapping tremor – CO2 retention – type 2 respiratory failure – e.g. COPD
Head and neck
Conjunctival pallor – ask patient to lower an eyelid to allow inspection – anaemia is associated with pallor
Horner’s syndrome – ptosis / constricted pupil (miosis) /anhidrosis on affected side / enophthalmos
Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue
Jugular venous pressure (JVP) – a raised JVP may indicate pulmonary hypertension / fluid overload 
Ensure the patient is positioned at 45°
Ask patient to turn their head away from you
Observe the neck for the JVP – located inline with the sternocleidomastoid
Measure the JVP – number of cm measured vertically from the sternal angle to the upper border of pulsation
Examine the sacrum for oedema (fluid overload in cor pulmonale)
Examine the legs:
Pitting oedema (fluid overload in cor pulmonale)
Assess the calves for signs of deep vein thrombosis
Inspect for evidence of erythema nodosum (associated with sarcoidosis)

11. Inspection Scars: Small mid-axillary scars (e.g. chest drains)
Horizontal postero-lateral scars (thoracotomy from e.g. lobectomy/pneumonectomy)
Skin changes – may indicate recent or previous radiotherapy – erythema / thickened skin
Asymmetry – major surgery:
Pneumonectomy (usually for cancer)
Thoracoplasty (rib removed / previously used to treat tuberculosis)
Deformities – barrel chest (COPD) / pectus excavatum and carinatum

12. Palpation Tracheal position:
Ensure patient’s neck musculature is relaxed – chin slightly downwards
Dip index finger into the thorax beside the trachea
Then gently apply side pressure to locate the trachea
Compare this space to the other side of trachea using the same process
A difference in the amount of space between the sides suggests deviation
The trachea deviates away from pneumothorax and large pleural effusions
The trachea deviates towards lobar collapse and pneumonectomy 
Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique
Cricosternal distance (no commonly done in practice):
Measure the distance between the suprasternal notch and cricoid cartilage using your fingers
In normal healthy individuals the distance should be 3-4 fingers
If the distance is <3 fingers, this suggests lung hyperinflation
Keep in mind that this distance is actually based on the patient’s fingers 
So if their fingers are significantly different in size from your own, it may be worth checking with theirs
Apex beat:
Normal position is 5th intercostal space – mid-clavicular line
Right ventricular heave is noted in cor-pulmonale (right heart failure secondary to chronic hypoxic lung diseases such as COPD or ILD)
Chest expansion:
Place your hands on the patient’s chest, inferior to the nipples
Wrap your fingers around either side of the chest
Bring your thumbs together in the midline, so that they touch
Ask patient to take a deep breath
Observe movement of your thumbs, they should move apart equally
If one of your thumbs moves less, this suggests reduced expansion on that side
Reduced expansion can be caused by lung collapse / pneumonia
Lymph nodes
Palpate the following areas:
Anterior and posterior triangles
Supraclavicular region
Axillary region
Lymphadenopathy may indicate infective/malignant pathology – lung cancer / tuberculosis / sarcoidosis

13. Percussion Technique is very important!
1. Place your non-dominant hand on the chest wall
2. Your middle finger should overlie the area you want to percuss (between ribs)
3. With your dominant hand’s middle finger, strike middle phalanx of your non-dominant hand’s middle finger
4. The striking finger should be removed quickly, otherwise you may muffle resulting percussion note
Percuss the following areas, comparing side to side:
Supraclavicular (lung apices)
Infraclavicular
Chest wall (3-4 locations bilaterally)
Axilla
Types of percussion note
Resonant – this is a normal finding
Dullness – this suggests increased tissue density – consolidation / fluid / tumour / collapse
Stony dullness – this suggests the presence of a pleural effusion
Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – e.g. pneumothorax

14. Auscultation https://www.youtube.com/watch?v=TlgP8MzlMaw
Assess quality:
Vesicular (normal)
Bronchial (harsh sounding – similar to auscultating over the trachea – inspiration and expiration are equal and there is a pause between) – associated with consolidation
Assess volume:
Quiet breath sounds suggest reduced air entry – consolidation / collapse / pleural effusion
State reduced breath sounds rather than reduced air entry when presenting
Added sounds:
Wheeze – asthma / COPD
Coarse crackles – pneumonia / bronchiectasis / fluid overload
Fine crackles – pulmonary fibrosis
Vocal resonance:
Ask patient to say “99” repeatedly and auscultate the chest again
Increased volume over an area suggests increased tissue density (especially if there is a dull percussion note over the same area) – consolidation / tumour / lobar collapse
Decreased volume over an area (especially if there is an associated dull percussion note) suggests fluid outside of the lung (pleural effusion)

15. ADJUNCTS TO ASSESSMENTBP
Pulse Oximetry
PEFR
ECG
CXR
ABG BM

16. When to consider referral
If investigations are indicated that you can’t complete
Features associated with presence or risk of serious illness that usually require emergency hospital admission include:
Stridor.
Altered level of consciousness or acute confusion.
Significant respiratory effort (particularly if the person is becoming exhausted).
Elevated respiratory rate.
Oxygen saturation less than 92%.
Cyanosis.
Tachycardia.
Hypotension.
Peak expiratory flow rate less than 50% of predicted.
Immunosuppression or other significant comorbidity.
Pregnancy or postnatal period.
Elderly or very frail people.
People who are unable to cope at home.
Poor or deteriorating general condition.

17. Time to practice History Site Onset Characteristics Radiation
Associations
Time
Exacerbating / relieving factors
Severity
Past Medical History
MJTHREADS
Drug History
Recreational drugs
Immunisations
Allergies
Social History
Family History
Examination
ABCDE
GRIPPAS
Get into pairs and choose an ailment

18. Case 1
COPD
Chronic obstructive pulmonary disease (COPD) is a lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.
Common progressive disease, very undiagnosed affecting % of population 1
thoracic.org.uk/document-library/audit- and-quality-improvement/cap-and- copd-care-bundle-docs-2016/copd- admissions-care-bundle/

19. Case 2
Asthma
Asthma is a chronic disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person.
Symptoms may occur several times in a day or week in affected individuals, and for some people become worse during physical activity or at night.
thoracic.org.uk/document-library/audit- and-quality-improvement/asthma-care- bundle/annex-1-care-bundle-sheet/

20. Case 3
Chest Infection
A chest infection is an infection of the lungs or airways. The main types of chest infection are bronchitis and pneumonia
Most bronchitis cases are caused by viruses, whereas most pneumonia cases are due to bacteria.
infections-adult#!scenario:1
score-pneumonia-severity

21. Case 4 TB
Tuberculosis (TB) is an infectious disease, it generally affects the lungs, but can also affect other parts of the body. Most infections don’t have any symptoms, in which case it is known as latent. About 10% of latent infections progress to active disease which, if left untreated, kills about half of those infected. /

22. Case 5
Anaemia
Anemia is usually defined as a decrease in the total amount of red blood cells or haemaglobin in the blood. It can also be defined as a lowered ability of the blood to carry oxygen.
deficiency#!scenario

23. Case 6 PE
A pulmonary embolism is a blockage in the pulmonary artery, the blood vessel that carries blood from the heart to the lungs.
embolism#!scenario
pulmonary-embolism

24. Case 7
Heart Failure
Heart failure is a clinical syndrome of symptoms (eg breathlessness, fatigue) and signs (eg oedema, crepitations) resulting from structural and/or functional abnormalities of cardiac function which lead to reduced cardiac output or high filling pressures at rest or with stress. 8

25. Case 8
Pneumothorax
Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space between the visceral and parietal pleura of the lung), which can impair oxygenation and/or ventilation.
9/documents/major-trauma-full- guideline2
thoracic.org.uk/document- library/clinical-information/pleural- disease/pleural-disease-guidelines- 2010/appendix-3-spontaneous- pneumothorax-poster-pleural-disease- guideline/

26. Case 9
DKA
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes.
/ifp/chapter/diabetic-ketoacidosis

27. Case 10
Panic attack
Panic attacks are sudden periods of intense fear usually last between 5 and 20 minutes 3

28. In Summary https://www.youtube.com/watch?v=Ahg6qcgoay4
So we have had a look at the respiratory system,
The respiratory examination
And some common conditions and how to treat them!
Most importantly keep an open mind 

29. Any questions? ?