2.  The HEENT, or Head, Eye, Ear, Nose and Throat Exam is usually the initial part of a general physical exam, after the vital signs.  Like other parts of the physical exam, it begins with inspection, and then proceeds to palpation.  It requires the use of several special instruments in order to inspect the eyes and ears, and special techniques to assess their special sensory function.  Review Terminology

4.  The skull is composed of 7 bones (paired frontal, parietal, temporal and one occipital) separated by suture lines. Skull and facial bones are used to localize physical complaints and findings to specific areas of the head and face  The fused frontal, zygomatic, nasal, ethmoid, lacrimal, sphenoid and maxillary bones form the bony structure of the face, along with the mandible.  Facial cavities include the orbits, nasal and oral cavities. The palpebral fissures, nasolabial folds, zygomatic arch are major facial landmarks.facial landmarks

5.  There are three paired salivary glands - the parotid, submandibular and sublingual glands.  They are located anterior to the ear, just medial to the angle of the mandible, and between the mandible and tongue, respectively.  Lymph nodes of the head include: Lymph nodes ◦ Occipital ◦ Preauricular ◦ Postauricular ◦ Cervical ◦ Submandibular ◦ Submental

6. Inspection  Skull: Observe the patient's facial expression and appearance. Look for symmetry, size, shape, edema, masses and involuntary movements  Hair: Observe quantity, distribution, texture, pattern of any hair loss. Look for lice or nits (the eggs of lice).  Scalp: Part the hair in several places and look for scaliness, erythema, skin lesions and nodules.

7. Palpation  Palpate with finger pads.  Generally, palpation is done only if patient symptomatic (head pain, trauma, etc.)  Skull: deformity from trauma, muscular tenderness from tension headaches  Temporal arteries: thickening, tenderness, or absent pulse in temporal arteritis  Hair: texture may change in thyroid disease, becoming more coarse.

8.  : External earExternal ear:  Auricle (or pinna) and external auditory canal (EAC) are cartilage covered with thin, sensitive skin  Cerumen secreted from distal 1/3 of canal- protects skin Middle ear:  Tympanic membrane (TM) normally looks "pearly gray"  Pars tensa- inferior 2/3  Pars flaccida- superior 1/3 (covers the chorda tympani)  Umbo- where malleus attaches to TM, pulling the TM into a conical shape  Malleus- manubrium (handle) and short process are visible  A retracted TM makes the short process prominent  Light reflex- cone of light that radiates anterior/inferior from the umbo  Eustachian tube- equalizes middle ear pressure

9. Inner ear:  The cochlea and semicircular canals

11. Inspection and palpation ◦ Inspect size, shape, position, discharge, lesions ◦ Palpate for tenderness, any lesions  gross hearing acuity: normal voice, whisper test, Weber and Rinne  Internal ear (behind tympanic membrane) – otoscope can look through TM

12. Inspection  External ear  observe position and shape, size, trauma.  inspect for symmetry, lesions, drainage  Possible findings ◦ Tophi- deposits of uric acid crystals found in patients with gout ◦ Chondritis- infection of cartilage, often caused by piercing ◦ Cauliflower"-repeated trauma causes cartilage necrosis ◦ Otitis externa- "swimmer's ear", pulling on lobe often painful

13. Inspection Middle ear – Otoscopic exam  Technique ◦ Use largest speculum that is comfortable ◦ Insert otoscope slowly, avoiding bumping the canal - "Look your way in" - while manipulating the auricle. ◦ In an adult pull back and up to straighten the auditory canal ◦ In an infant and child, pull auricle back and down to straighten the auditory canal. ◦ Cerumen removal may be necessary ◦ Cerumen spoon- often causes EAC bleeding ◦ Irrigation - contraindicated if TM perforation ◦ Removal with direct visualization

14. Inspection Inner ear Pneumatic Otoscopy  assesses mobility and color of TM  Air pressure should move TM-  light reflex looks like a sail in wind  See Normal Mobility videoNormal Mobility video  Effusion (fluid in middle ear) will hamper TM mobility  Retraction from eustachian tube dysfunction may allow movement only with negative pressure  See Abnormal Mobility videoAbnormal Mobility video

15. Findings  Mobility ◦ Bulging, no mobility Pus in middle ear- otitis media ◦ Retracted, no mobility -Eustacian tube dysfunction +/- effusion  Color ◦ Red Infection, crying ◦ Deep red or blue Blood (from trauma) ◦ White flecks, plaques Healed inflammation ◦ Bubbles Serous fluid

16. Otitis Media with Effusion Acute Otitis Media

17. Hearing  Simple: assess the ability of the patient to hear a sequence of equally accented words (3-5-2-4) whispered from a distance of a couple of feet.

18. Hearing  Rinne Test: ◦ Compares bone and air conduction ◦ Place tip of vibrating tuning fork on the mastoid process behind the ear ◦ Ask the patient to indicate when he no longer hears the vibrating turning fork ◦ Hold the fork in front but not touching the ear canal to test air conduction ◦ Normally patient can hear vibration better that feeling them

19. Hearing  Weber Test: ◦ Place the tip of a vibrating fork on the center of patient's forehead ◦ Normally sound is heard equally in both ears

20.  External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. External eye  Internal eye: Light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina

22.  Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula.  These structures are viewed with the ophthalmoscope. Findings on the retina are described in relationship to the quadrants of the eye, which are determined by their proximity to the nose (medial) or temple (lateral).

24.  Inspection and Palpation ◦ Inspect and palpate lids, lashes, inspect eye position and symmetry and position, symmetry and size of pupils ◦ Visual acuity with Snellen chart  20/20 - first number (numerator) is distance from chart  Second number is distance at which a normal eye could have read that line  Always record if tested cc (with correction)

25. Inspection  Be systematic - inspect eyebrows, lids, and globe including conjunctivae.  Findings: ◦ Eyebrows :  Loss of lateral growth may suggest hypothyroidism  Xanthelasma -irregular, slightly raised yellow periorbital lesions may suggest lipid disorder ◦ Eyelids :  Ptosis (TOH-sis)- if upper lid covers part of pupil (muscle weakness or neurologic lesion

26. Visual fields: Confrontation test estimates peripheral vision  may be important in glaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumor  Technique - face patient at eye level. Ask patient to cover one eye. Slowly move your fingers from outside the patient's peripheral visual field towards the center of the patient's vision. Ask the patient to tell you when he sees your fingers  Test without, then with corrective lenses

27. Pupils: Check direct and consensual response to light  Shine light source briefly into pupil, observing for constriction. Shine again into pupil, and observe for constriction of contralateral eye.  Check accommodation (papillary constriction with near focus)  Ask patient to look at finger held several feet from face, then to look at finger brought just beyond the end of the patient's nose.

28. Findings:  Miosis (my-OH-sis) if <2mm (narcotic use, elderly)  Mydriasis (mi-DRY-ah-sis) if >6mm (head injury, drugs)  Anisocoria - unequal pupil size, may be normal variation

29. Extraocular eye movements  Test CN III, IV, VI and 6 extraocular muscles (EOM).  Try the test animation.test animation  Technique ◦ Patient watches your finger move through 6 "cardinal positions" ◦ Observe for coordinated movement, nystagmus (or "jerkiness" of motion.

30. Extraocular eye movements  Findings ◦ Lack of coordinated movement denotes problem with cranial nerves or muscle strength/alignment. ◦ Nystagmus- involuntary rhythmic eye movements ◦ A few beats of horizontal nystagmus at extreme lateral gaze is normal ◦ Lid lag- exposure of sclera over iris as patient moves eyes inferiorly (found in hyperthyroidism)

31. Vision testing  Should be done with any visit involving an eye complaint  Used to screen children for visual problems  Acuity: ◦ Far vision - test at 20 feet with Snellen chart ◦ Patient covers one eye, and is instructed to read the smallest line possible. Patient must correctly read half of symbols on line. Repeat for other eye. ◦ Near vision - test at 14 inches with pocket chart ◦ Patient covers one eye, and is instructed to read smallest line possible. Repeat for other eye. ◦ test without, then with corrective lenses

32.  Goal : Examine optic disc, arteries, veins, and retina.  Technique ◦ Allow pupils to dilate ◦ darken room ◦ use least light possible from scope (dim, small aperture) ◦ may consider mydriatic drops (if you do, examine for shallow anterior chamber to avoid acute narrow-angle glaucoma)  Positioning ◦ Examine patient's right eye with your right eye and scope in right hand, patient's left eye with your left eye and scope in left hand ◦ Keep your other eye open ◦ One hand on patient's head for stabilization

33.  Finding the optic disc ◦ While asking the patient to look straight ahead, Identify the red reflex, from a distance of 12 to 18 inches, at an angle of 15 degrees from the midline. ◦ Using a long focal length lens ("0" or a red or black number) ◦ Move slowly in towards patient until you are 1 to 2 inches from pupil. ◦ Trace vessels back to disc ◦ Finally, have patient look at light to examine macula

34.  Findings ◦ Papilledema- vague disc margins, suggests increased intracranial pressure (ICP) ◦ Hemorrhages- from diabetes, glaucoma, hypertension ◦ Exudates

35.  Vessels: ◦ Arterioles- brighter, redder, narrower (2/3 to 3/5 diameter of venules) ◦ Venules- more purple, wider ◦ Venous pulsations- normal, but not always present ◦ If present, rule out increased ICP ◦ "Nicking" of veins where arteries cross- seen in hypertension

36.  External nose formed by bone and cartilage.  The nares, the anterior nasal openings, are surrounded by cartilaginous ala nasi and columella.

37.  The nasal bridge is formed by the frontal and maxillary bones.  The septum divides the nose into two anterior cavities.  Kiesselbach's plexus is a grouping of small blood vessels on the anterior septum. It is a frequent site of nosebleeds.  The turbinates form the lateral walls of the nose, and are curved bony structures covered by mucous membranes. They run horizontally within the nasal cavity. There are three paired turbinates - inferior, middle and superior.nasal cavity  The sinuses are air-filled and paired extensions of the nasal cavities within the bones of the skull. sinuses ◦ Maxillary sinus - present at birth ◦ Ethmoid and sphenoid sinuses - present by 1 year ◦ Frontal sinus - present by 10 years

38.  Inspection, palpation, percussion  Inspect color of mucosa, presence of discharge ◦ There is a nasal speculum – most people don’t like it ◦ Assess for patency  Palpate for tenderness  Percuss for tenderness over frontal and maxillary sinuses

39. Inspection  Check patency by asking patient to occlude one nostril, and then breath through opposite nostril. Repeat for opposite nostril.  Inspect external nose for symmetry, inflammation and lesions ◦ findings  Deformity trauma  Discharge infection, trauma, foreign body  Flaring respiratory distress ◦ Transverse crease- from "allergic salute"

40.  Frontal and maxillary sinuses are the most accessible to examination  Palpation and percussion may or may not be helpful – because different examiners will frequently have different findings when examining the same patient (sinus palpation or percussion is not reliable).

41.  Transillumination of maxillary sinuses:  Darken room completely  Patient seated with head back, mouth open and eyes closed  Light source just lateral to nose and inferior and medial to eye  Look for light transmitted through sinuses to hard palate  Should appear as dull-red cresent-shaped glowing areas

42.  Lack of transillumination suggests that sinus is filled with secretions  Findings suggesting diagnosis of sinsusitis: "Does This Patient Have Sinusitis?" JAMA 270(10): 1242-6  The following increase the likelihood that your patient has sinusitis: ◦ History of colored nasal discharge ◦ Poor response to decongestants ◦ Maxillary tooth pain ◦ physical exam showing purulent nasal discharge and abnormal maxillary sinus transillumination

43.  The Oral Cavity is comprised of the vestibule and the mouth:Oral Cavity ◦ Vestibule - space between the buccal mucosa to the outer gingival ◦ Mouth - tongue, teeth and gums.  Roof of mouth formed by the hard and soft palate  Floor of mouth formed by soft tissue anchored to the mandible. ◦ Tongue anchored to floor of oral cavity posteriorly, and by frenulum anteriorly  Dorsal surface covered by thick mucosa that supports the filiform papillae. ◦ Teeth and gums  32 adult teeth: 4 incisors, 2 canines, 4 premolars, 6 molars in each jaw.  Gingiva attach to the alveolar tissue and normally cover the root and neck of each tooth.

44. ◦ Two paired salivary ducts enter the oral cavity  Wharton's ducts, from the submandibular glands, open on each side of the tongue's frenulum  Stensen's ducts, from the parotid glands, open onto the buccal mucosa across from the second molar of the upper jaw.  The sublingual gland drains through a number of smaller, not readily visible ducts (Ducts of Rivinus).  The oropharynx is separated from the mouth by the anterior tonsillar pillars. ◦ Tonsils lie between the anterior and posterior tonsillar pillars

45.  Inspection, palpation, auscultation  Inspect and palpate lips, tongue, oral cavity, tonsils, pharynx (color, moisture), teeth, breath, presence of exudate, erythema, lesions, palate  Enlarged tonsils are graded  Grade 1 – wnl  Grade 2 – tonsils b/w pillars and uvula  Grade 3 – tonsils touching uvula  Grade 4 – tonsils touching each other (kissing tonsils )

47. Inspection ◦ Use a light source (otoscope or pen-light). ◦ Use a gloved hand, or tongue depressor (preferable - some patients, particularly children or confused older adults may bite!), to gently retract structures (buccal wall, tongue) as necessary. Tongue blade, if needed, is more palatable if you wet it in the sink first.

48. Inspection ◦ Inspect lips, buccal mucosa for color, hydration, ulceration and lesions. ◦ Inspect gingival and teeth for color, bleeding, inflammation, caries, missing teeth, ulceration and lesions. ◦ Inspect hard palate for color, symmetry, ulceration and lesions.

49.  To visualize the posterior oropharynx: ◦ ask the patient to say "AAAAAH." ◦ In some patients, oropharynx is better seen if patient does not extend tongue. ◦ If needed, may place a tongue depressor on tongue on the distal half and gently depress it.

50.  To visualize the posterior oropharynx: ◦ In some young children, asking them to open wide and breathe rapidly in and out will allow you to visualize the posterior oropharynx. ◦ Inspect for color, edema, ulcerations, exudates, and lesions  Inspect tongue and floor and roof of mouth for symmetry, color, edema, ulcerations, and lesions

51.  Note breath odor ◦ Alcholol in alcoholics ◦ Urinous in uremia ◦ Sweetish fruity in DM AND DKA ◦ Musty (fetor hepaticus) in sever liver disease.

52.  Percussion ◦ Done only as needed, in patients who have potential dental sources of oral pain. ◦ Gently tap or press on teeth that may be a source of pain using a tongue blade will identify which teeth are affected.

53.  Palpation ◦ Done only as needed, primarily in patients whom you suspect may have squamous cell cancer of the head and neck, or when assessing a lesion in the oropharynx. ◦ Use a gloved hand, and warn the patient that you may inadvertently gag him. ◦ Gently palpate the surface of the lesion with one or two fingers to assess its size, consistency (soft, firm, hard), underlying induration and tenderness. ◦ Use bimanual palpation (examination fingers placed in mouth, other fingers below the jaw, to palpate the soft tissues on the floor of the mouth and the tongue.

54. Findings  Lips ◦ Angular cheilitis (key-LY-tis) - fissures at corners of mouth ◦ Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer ◦ Angioedema - allergic swelling ◦ Herpes labialis- "cold sore" ◦ Carcinoma

55. Findings  Colors: ◦ Pale- anemia ◦ Blue- cyanosis ◦ Red- CO poisoning  Buccal Mucosa: ◦ Thrush- adherent white patches

56.  Tongue: ◦ Geographic tongue - so-called because it resembles a map ◦ Smooth - may indicate vitamin deficiency ◦ Glossitis - erythematous, sometime swollen ◦ Black hairy tongue ◦ Varicosities ◦ Nonhealing ulcer or nodule- consider cancer

57.  Oropharynx ◦ Bifid uvula- may indicate cleft palate ◦ Asymmetric movement of soft palate- lesion of CN IX or X ◦ Erythema, exudate- tonsillitis ◦ Asymmetric tonsillar swelling (often with deviation of uvula) - peritonsillar abscess ◦ "Cobble-stone" - swelling of lymphoid tissue, often secondary to allergies. ◦ Post-nasal drip

58.  Triangles of the neck ◦ Anterior: Bordered by mandibles and sternocleidomastoids (SCM) ◦ Posterior: Bordered by anterior margin of trapezius, posterior margin of the SCM, and superior margin of the clavicle

60.  Lymph nodes: Lymph nodes ◦ Occur in groups; size is tiny to 1cm ◦ Enlargement can provide clue to infection or malignancy ◦ Function:  Defend against invading organisms  A partial barrier (but also a pathway) to spread of malignancy ◦ Lymphoid tissue mass increases rapidly, especially between ages 6-9, peaks at 9-12 and then regresses to adult levels. (This includes tonsils, which can appear very large!) ◦ Nodes of the neck include the posterior cervical, anterior cervical and supraclavicular

61.  Trachea ◦ Midline, position may be altered by cervical or intrathoracic disease or injury. ◦ Understanding the relationship of the thyroid cartilage, cricoid cartilage and crico-thyroid membrane important for emergent access to the trachea (cricothyroidotomy) in situations when intubation of the trachea via the oropharynx is not possible. Also very helpful in finding the isthmus of the thyroid. See Anterior Neck. Anterior Neck  Thyroid ◦ Lobular gland, located on each side of trachea, joined by an isthmus. ◦ Isthmus located below the thyroid cartilage

62. Inspection  Observe how the patient holds their head. Inspect the neck for symmetry, masses, goiter or scars Palpation  Palpate the trachea with the thumb on one side and the index and middle finger on other side of trachea, or with the index and middle finger of opposing hands.  Trachea: should be midline, palpate superior to suprasternal notch  Deviation may be sign of a mass or a tension pneumothorax  Downward "tugging" may suggest aortic aneurysm

63. Lymph nodes:  Examine with each region (for example, neck when examining neck, axilla when examining chest), or as a separate organ system (all of lymph nodes at one time).  Gentle pressure with pads of fingers 2,3,and/or 4  Compare bilaterally  Patients will often hyperextend neck for exam- encourage them to flex gently

64. Findings:  Size: < 1 cm normal. (small, movable, discrete, nontender nodes often called "shotty")  Consistency: hard or rubbery  Mobility: mobile or fixed  Tenderness: suggests inflammation  Warmth: suggests inflammation

65. Findings:  If you find enlarged nodes, check drainage areas for infection, inflammation, or cancer  Important example: "Virchow's node"- left supraclavicular often a clue to abdominal or thoracic malignancy  Common example: Tonsillar or retropharyngeal nodes often enlarged in strep throat

66. Inspection  Inspect the thyroid with the neck slightly extended, using tangential lighting. Goiter is essentially ruled out if thyroid gland is not visible with neck extension. (JAMA 273; 10: 813-817)

67. Palpation:  palpate for size, nodules, and tenderness  Technique ◦ Anterior or posterior approach ◦ Relax neck by using neutral position, also may further relax muscles on one side by tilting toward that side ◦ Identify the appropriate level of the thyroid isthmus ◦ Gently retract the trachea to the opposite side of the lobe you are palpating. ◦ Have the patient swallow a sip of water while you palpate

68.  Changes in respiratory status can happen very slowly, or very quickly, so respiratory status is assessed carefully, and frequently

69.  Review Terminology  Inspect, Palpate, Percuss (normal note is resonance), Auscultate (normal is clear and equal bilaterally) ◦ Auscultate using diagram  Assess and document respiratory rate, rhythm, and effort

71. Inspection  Inspect through one complete breath cycle  Assess size and shape of thorax ◦ Look for deformities ◦ Chest wall abnormalities, accessory muscle use ◦ Skeletal abnormalities ◦ Barrel chest from asthma or COPD

72. Inspection  Presence of supernumery nipples  For efficiency, you usually assess posterior chest first  Intercostal spaces (ICS) are named according the rib they lie beneath ◦ 4 th rib lies superior to 4 th ICS

75. Percussion  Over intercostal spaces to assess density ◦ Normal  loud, low pitched, resonant note ◦ increase air volume (emphysema)  very loud, low pitched hyperresonant note ◦ Consolidation (fluid)  dull, flat note

76. Percussion  To determine diaphragmatic location and excursion ( difference in location of the diaphragm when the lung are expanded and emptied) ◦ Percuss on the back of the chest between the vertebral column and the scapula from the 6 th rib down with the lung expanded ◦ Repeat with the lungs emptied ◦ The diaphragm is located where the percussion note changes from resonant to dull ◦ NL excursion is  3-5 cm F, 5-6 cm M

77. Palpitation  Palpate for masses, pulsations, cepitations and tactile fremitus  To assess for tactile fremitus place the palm of the hand on the chest and have the patient say 99 or 123.

78.  Anxious expression  Suprasternal & intercostal retractions  Nasal flaring  Circumoral cyanosis  Hyperexpanded chest ◦ ALWAYS REMEMBER YOUR ABCs

79. Auscultation  Using a stethoscope, between the scapulae and vertebral column  Instruct patient to breath deeply and slowly  Auscultate using diaphragm, use a systematic approach, compare each side to the other, document when and where sounds are heard  Normal breath sounds: tracheal, bronchovesicular, bronchial, and vesicular ◦ Abnormal breath sounds are called adventitious sounds

80. Auscultation  Trachea  tracheal Large central bronchi  bronchovesicular  Small airways distal to central bronchi  bronchial  Small lateral airways  vesicular  These sounds are considered abnormal if heard over other areas of the lung  Other abnormal breaths sounds ◦ Wheeses, rhonchi, stridor, crackles

81.  Wheeze - may be heard with or without stethoscope high-pitched squeaky musical sound; usually not changed by coughing; Document if heard on inspiration, expiration, or both; May clear with cough ◦ Noise is caused by air moving through narrowed or partially obstructed airway ◦ Heard in asthma or FBA  Stridor - may be heard without stethoscope, shrill harsh sound on inspiration d/t laryngeal obstruction

82.  Crackles - heard only with stethoscope (rales): ◦ fine, medium, coarse short crackling sounds (think hair); May clear with cough ◦ Most commonly heard in bases; easier to hear on inspiration (but occurs in both inspiration and expiration)  Gurgles - heard only with stethoscope (rhonchi): o Low pitched, coarse wheezy or whistling sound o usually more pronounced during expiration when air moves through thick secretions or narrowed airways o sounds like a moan or snore; best heard on expiration (but occur both in and out)

83.  Friction rub ◦ Grating, creaking, or rubbing sound heard on both inspiration and expiration; not relieved by coughing; due to pleural inflammation  Document breath sounds as clear, decreased or absent, compare right to left, and describe type and location of any adventitious sounds

84.  Review Terminology  Inspection and palpation ◦ Men have some glandular tissue beneath nipple; women have glandular tissue throughout breast and into axilla  Largest portion of glandular tissue in women in in upper outer quadrant ◦ Inspect with patient in sitting and supine position ◦ Inspect for size, symmetry, contour (shape), and apperance of skin ◦ look for any areas of hyperpigmentation, retraction or dimpling, edema, ◦ visible masses, localized flattening, rashes, ulcers and discharge from nipples

85.  Palpation ◦ Palpate breasts, areolae, nipples and axillary lymph nodes in both men and women ◦ Palpate for nidules, indurations, areas of tenderness or increased warmth. ◦ Palpate lymph nodes of the axilla for size, consistency, and tenderness.

87. ◦ Newborns – may have breast swelling and/or milky discharge from nipples for up to 2 weeks ◦ Tanner Staging is a sexual maturity rating; female breast development is one of the things rated (5 stages) ◦ Gynecomastia – enlargement of breast tissue in males; often occurs during puberty, and often affects only one breast, or affects one more so size is not symmetric ◦ Pregnant women – breasts enlarge as glandular tissue responds to pregnancy hormones to prepare for breastfeeding ◦ Elderly – glandular tissue is replaced by fatty tissue, and elasticity of connective tissue is lost after menopause, both contribute to breasts becoming pendulous or flacci d

88.  The term encompasses a wide variety of objective methods to assess lung function.  Examples include: ◦ Spirometry ◦ Lung volumes by helium dilution or body plethysmography ◦ Blood gases ◦ Exercise tests ◦ Diffusing capacity ◦ Bronchial challenge testing ◦ Pulse oximetry

89.  Add to diagnosis of disease (pulmonary and cardiac)  May help guide management of a disease process  Can help monitor progression of disease and effectiveness of treatment  Aid in pre-operative assessment of certain patients

90. Diagnostic  To evaluate symptoms, signs, or abnormal laboratory tests  -Symptoms: dyspnea, wheezing, orthopnea, cough, phlegm production,  chest pain  -Signs: diminished breath sounds, overinflation, expiratory slowing,  cyanosis, chest deformity, unexplained crackles  -Abnormal laboratory tests: hypoxemia, hypercapnia, polycythemia,  abnormal chest radiographs  To measure the effect of disease on pulmonary function  To screen individuals at risk of having pulmonary diseases  -Smokers  -Individuals in occupations with exposures to injurious substances  -Some routine physical examinations  To assess preoperative risk  To assess prognosis (lung transplant, etc.)  To assess health status before enrollment in strenuous physical activity

91. Monitoring  To assess therapeutic interventions  -bronchodilator therapy  -Steroid treatment for asthma, interstitial lung disease, etc.  -Management of congestive heart failure  -Other (antibiotics in cystic fibrosis, etc.)  To describe the course of diseases affecting lung function  -Pulmonary diseases  Obstructive airways diseases  Interstitial lung diseases  -Cardiac diseases  Congestive heart failure  -Neuromuscular diseases  Guillain-Barre Syndrome  To monitor persons in occupations with exposure to injurious agents  To monitor for adverse reactions to drugs with known pulmonary toxicity

92. Disability/Impairment Evaluations To assess patients as part of a rehabilitation program -Medical -Industrial -Vocational To assess risks as part of an insurance evaluation To assess individuals for legal reasons -Social Security or other government compensation programs -Personal injury lawsuits -Others Public Health Epidemiologic surveys -Comparison of health status of populations living in different environments -Validation of subjective complaints in occupational/environmental settings Derivation of reference equations

93.  “Spirometry is a medical test that measures the volume of air an individual inhales or exhales as a function of time.

94.  4 volumes: inspiratory reserve volume, tidal volume, expiratory reserve volume, and residual volume  2 or more volumes comprise a capacity.  4 capacites: vital capacity, inspiratory capacity, functional residual capacity, and total lung capacity

95.  Tidal Volume (TV): volume of air inhaled or exhaled with each breath during quiet breathing  Inspiratory Reserve Volume (IRV): maximum volume of air inhaled from the end- inspiratory tidal position  Expiratory Reserve Volume (ERV): maximum volume of air that can be exhaled from resting end-expiratory tidal position

96.  Residual Volume (RV): ◦ Volume of air remaining in lungs after maximium exhalation ◦ Indirectly measured (FRC-ERV) not by spirometry

97.  Total Lung Capacity (TLC): Sum of all volume compartments or volume of air in lungs after maximum inspiration  Vital Capacity (VC): TLC minus RV or maximum volume of air exhaled from maximal inspiratory level  Inspiratory Capacity (IC): Sum of IRV and TV or the maximum volume of air that can be inhaled from the end- expiratory tidal position

98.  Functional Residual Capacity (FRC): ◦ Sum of RV and ERV or the volume of air in the lungs at end-expiratory tidal position ◦ Measured with multiple- breath closed-circuit helium dilution, multiple- breath open-circuit nitrogen washout, or body plethysmography (not by spirometry)

99.  A spirometer can be used to measure the following: ◦ FVC and its derivatives (such as FEV1, FEF 25-75%) ◦ Forced inspiratory vital capacity (FIVC) ◦ Peak expiratory flow rate ◦ Maximum voluntary ventilation (MVV) ◦ Slow VC ◦ IC, IRV, and ERV ◦ Pre and post bronchodilator studies

100.  The volume exhaled after a subject inhales maximally then exhales as fast and hard as possible.  Approximates vital capacity during slow expiration, except may be lower (than true VC) patients with obstructive disease How is this done?

101.  Check spirometer calibration.  Explain test.  Prepare patient. ◦ Ask about smoking, recent illness, medication use, etc.

102.  Patient performs the maneuver ◦ Patient assumes the position ◦ Puts nose clip on ◦ Inhales maximally ◦ Puts mouthpiece on mouth and closes lips around mouthpiece (open circuit) ◦ Exhales as hard and fast and long as possible ◦ Repeat instructions if necessary –be an effective coach ◦ Repeat minimum of three times (check for reproducibility.)

103.  Two ways to record results of FVC maneuver: ◦ Flow-volume curve---flow meter measures flow rate in L/s upon exhalation; flow plotted as function of volume ◦ Classic spirogram---volume as a function of time

105.  Normal values vary and depend on: ◦ Height ◦ Age ◦ Gender ◦ Ethnicity

107.  FEV 1 ---the volume exhaled during the first second of the FVC maneuver  FEF 25-75%---the mean expiratory flow during the middle half of the FVC maneuver; reflects flow through the small (<2 mm in diameter) airways  FEV 1 /FVC---the ratio of FEV1 to FVC X 100 (expressed as a percent); an important value because a reduction of this ratio from expected values is specific for obstructive rather than restrictive diseases

108.  Obstructive Disorders ◦ Characterized by a limitation of expiratory airflow so that airways cannot empty as rapidly compared to normal (such as through narrowed airways from bronchospasm, inflammation, etc.) Examples: ◦ Asthma ◦ Emphysema ◦ Cystic Fibrosis  Restrictive Disorders ◦ Characterized by reduced lung volumes/decreased lung compliance Examples: ◦ Interstitial Fibrosis ◦ Scoliosis ◦ Obesity ◦ Lung Resection ◦ Neuromuscular diseases ◦ Cystic Fibrosis

109. (Hyatt, 2003)

110.  Obstructive Disorders ◦ FVC nl or↓ ◦ FEV1 ↓ ◦ FEF25-75% ↓ ◦ FEV1/FVC ↓ ◦ TLC nl or ↑  Restrictive Disorders ◦ FVC ↓ ◦ FEV1 ↓ ◦ FEF 25-75% nl to ↓ ◦ FEV1/FVC nl to ↑ ◦ TLC ↓

111.  FVC  Interpretation of % predicted: ◦ 80-120% Normal ◦ 70-79%Mild reduction ◦ 50%-69% Moderate reduction ◦ <50% Severe reduction FEV1 Interpretation of % predicted: ◦ >75% Normal ◦ 60%-75% Mild obstruction ◦ 50-59% Moderate obstruction ◦ <49% Severe obstruction  60 y.o. subtract 5

112.  FEF 25-75%  Interpretation of % predicted: ◦ >79% Normal ◦ 60-79%Mild obstruction ◦ 40-59%Moderate obstruction ◦ <40% Severe obstruction  FEV1/FVC  Interpretation of absolute value: ◦ 80 or higher Normal ◦ 79 or lower Abnormal

113. (From Ruppel, 2003)

114.  Do FVC maneuver and then inhale as rapidly and as much as able.  This makes an inspiratory curve.  The expiratory and inspiratory flow volume curves put together make a flow volume loop.

115. (Rudolph and Rudolph, 2003)

116.  Helpful in evaluation of air flow limitation on inspiration and expiration  In addition to obstructive and restrictive patterns, flow-volume loops can show provide information on upper airway obstruction: ◦ Fixed obstruction: constant airflow limitation on inspiration and expiration—such as in tumor, tracheal stenosis ◦ Variable extrathoracic obstruction: limitation of inspiratory flow, flattened inspiratory loop—such as in vocal cord dysfunction ◦ Variable intrathoracic obstruction: flattening of expiratory limb; as in malignancy or tracheomalacia

117.  Obtain a flow-volume loop.  Administer a bronchodilator.  Obtain the flow-volume loop again a minimum of 15 minutes after administration of the bronchodilator.  Calculate percent change (FEV1 most commonly used---so % change FEV 1= [(FEV1 Post-FEV1 Pre)/FEV1 Pre] X 100).  Reversibility is with 12% or greater change.