1. Examination of the respiratory system
Leyla Swafe, FY1, NNUH

2. Directives
Examine the respiratory system
Examine patient´s chest

3. Overview Introduction Inspection Palpation Percussion Auscultation
Concluding remarks
OSCE video

4. Introduction Wash hands Introduce, explain, consent, expose
Position: supine at 45

5. Inspection: signs General inspection
Appearance: ill/distressed/pain/short of breath
Accessory muscles, pursed lip, wheeze, stridor
Nutritional statius: cachexia
Oxygen, fluids and medications
Sputum pot

6. Inspection/Observation:
A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to:
General comfort and breathing pattern of the patient.
Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep?
Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies some element of respiratory difficulty.
Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!

7. Video – respiratory distress

8. Beside Always look for a sputum pot! Inhalers
Yellow/green sputum –infection
Massive amounts of sputum – most likely bronchiectasis
Look for signs of blood –infection/malignancy
Inhalers

9. Flapping tremor

10. Cyanosis:
A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.

11. Clubbing
Clubbing:
Bulbous appearance of the distal phalanges of all fingers along
Concurrent loss of the normal angle between the nail base and adjacent skin.
Most commonly associated with conditions that cause chronic hypoxemia (e.g. severe emphysema), also associated with a number of other conditions.
However, in general it is neither common nor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing.

12. Nicotine staining

13. Pulse At the wrist you should take the patient’s pulse.
A bounding pulse may indicate carbon dioxide retention.
After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate.
This helps to keep it as natural as possible.

14. Inspection: signs Hands Wrist Nails Nicotine staining
Finger clubbing
Nicotine staining
Peripheral cyanosis
Warmth
Wrist
Flapping tremor / Fine tremor
Respiratory rate
Pulse

15. Inspection: signs Face Cushingoid Eyes Mouth Conjunctival pallor
Horners
Mouth
Central cyanosis

16. Inspection: signs Neck Nodes Tracheal position Cricosternal distance
Tracheal tug on inspiration
Nodes
Palpation of lymph nodes

17. Lymphadenopathy
Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow’s Node) as an enlarged node (Troisier’s Sign) may suggest metastatic lung cancer.

18. Chest wall deformities
Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's ability to breathe normally. A few common variants include:

19. Palpation
Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam.

20. Inspection: signs Chest A-P diameter Scars Chest drain sites
Deformity of chest/spine

21. Palpation
Trachea
Apex beat
Chest expansion

22. Chest wall deformities
Pectus excavatum: Congenital posterior displacement of lower aspect of sternum.
Kyphosis: Causes the patient to be bent forward.
Scoliosis: Condition where the spine is curved to either the left or right.
Barrel chest: Associated with emphysema and lung hyperinflation.

23. Tactile Fremitus:
Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall.

24. Pathologic conditions will alter fremitus. In particular:
Lung consolidation:
Consolidation occurs when the
normally air filled lung parenchyma
becomes engorged with fluid or tissue,
most commonly in the setting of
pneumonia. If a large enough segment
of parenchyma is involved, it can alter
the transmission of air and sound. In
the presence of consolidation, fremitus
becomes more pronounced.
Pleural fluid: Fluid, known as a pleural
effusion, can collect in the potential
space that exists between the lung and
the chest wall, displacing the lung
upwards. Fremitus over an effusion will
be decreased.

25. Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. In this model, an infiltrate is depicted by the blue coloration that has invaded the sponge itself (sponge on left). An effusion is depicted by the blue fluid upon which the lung is floating (sponge on right).

26. Percussion Start in supraclavicular fossa then work down
Compare side to side including axillae
Map out abnormalities

27. Auscultation

28. Auscultation

29. Auscultation Use diaphragm
Vesicular breathing (normal)/Bronchial breathing (pathological)
Decreased or absent breath sounds
Added sounds
Crepitations (cough)
Wheezes
Pleural rub
Vocal resonance
Vocal resonance ”say 99

30. Auscultation

31. General examination
Back
Sacral oedema
Ankles
Peripheral oedema

32. Causes of physical signs found on respiratory examination

33. Concluding remarks Observation chart (BP, temp, sats)
To Complete My Examination...
Observation chart (BP, temp, sats)
Abdominal Examination for hepatomegaly
Sacral or peripheral oedema
Investigations you may like to perform might include:
Chest x-ray
Sputum microscopy, culture and sensitivity
Pulse Oximetry
Arterial blood gas analysis
Spirometry
Peak expiratory flow rate

34. OSCE video