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

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

3. 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

4. Google … Physician

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

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

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

9. “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?

10. 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

11. 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

12. “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

14. 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

15. Digital Clubbing

16. 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

19. 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

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

21. Surface Anatomy

22. SURFACE ANATOMY OF THE CHEST

23. SURFACE ANATOMY OF THE CHEST

24. Where are the Lungs?

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

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

27. 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

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

35. 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

37. 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

38. 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

39. Tactile Fremitus

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

41. Percussion

42. 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

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

44. 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

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

46. 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)

47. 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

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

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

50. 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

51. Reading list http://www.youtube.com/watch?v=iqpm3c4ys6U