| Resp exam: Overall plan |
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Introduction (Use the acronym WIPER to prepare for the examination)
- W - Wash your hands
- I - Introduce yourself and confirm patient details
- P - Permission - gain consent to proceed with the examination, including explaining relevant details
- E - Expose the patient appropriately, gather Equipment
- R - Position the patient lying back at 45 degrees comfortably
Ask the patient to cough first to remove any phlegm that can add noises to the auscultatory findings. Ask the patient to breathe through an open mouth as less resistance pathway and more air shifted and so more to hear normal breathing pattern expiration more prolonged than inspiration 2:1
- Stand back and Inspect from end of bed
- Bedside table
- Sputum pots full of phlegm (bronchiectasis, COPD)
- Oxygen cylinder (Suggests hypoxia - COPD, Pneumonia etc.)
- Inhalers (COPD, asthma)
- Chest drain in place - is it swinging
- Nebulisers (COPD or Asthma)
- Peak flow charts (Asthma)
- Person
- Respiratory rate - normal 12-15/minute and breathing
- Hypoventilating - obese, oversedated, COPD "Blue bloater", raised ICP
- Hyperventilating: COPD, Asthma, LVF, Pneumonia, PE, Panic attack
- Intercostal indrawing of ribs suggests increased effort
- Prolonged expiratory phase - COPD, Asthma
- Tripod position in severe COPD
- Pursed lips respiration (COPD) : seen in emphysema as the patient maintains a positive airway pressure to prevent small airway collapse
- Audible wheeze (COPD/Asthma)
- Hoarse voice - Recurrent laryngeal nerve palsy from bronchogenic carcinoma
- Thin, cachexia - malignancy, end-stage COPD, pulmonary fibrosi
- Visible scars on chest
- Smell of cigarettes, Unkempt, emaciated - ? TB, Cancer, Alcoholism
- Cushingoid (steroid treatment/Cushing's disease/Paraneoplastic)
- Kyphosis and/or scoliosis (Ankylosing spondylitis -apical lung fibrosis)
- Respiratory rate - normal 12-15/minute and breathing
- Examine Hands
- Clubbing (suppurative conditions, lung cancer, fibrosis)
- Bulbous swelling of terminal phalanges with loss of angle of nail bed
- Aetiology unsure possibly circulating prostaglandins
- Associated with Hypertrophic pulmonary osteoarthropathy- onion skin like bone formation at the wrist associated with clubbing
- Causes of Clubbing
- Malignancy - Lung cancer, Mesothelioma
- Infection - Lung abscess, Empyema, Bronchiectasis
- Cryptogenic fibrosing alveolitis
- Endocarditis, Atrial myxoma
- Congenital cyanotic cardiac disease
- Cirrhosis, Congenital (AD)
- Inflammatory bowel disease
- Causes of Clubbing
- Tar (Nicotine) staining
- Wasting of small muscles
- Tremor + CO2 retention
- Cyanosis - central if lips blue
- Clubbing (suppurative conditions, lung cancer, fibrosis)
- Radial pulse
- Bounding pulse - CO2 retention
- Irregularly irregular - Atrial fibrillation
- Tachycardia - fever, distress, arrhythmias
- Respiratory rate
- Eyes
- Horner syndrome (Pancoast syndrome: Miosis and mild ptosis )
- Anaemia
- Jaunidiced (liver metastases with lung cancer)
- Conjunctiva - pale and anaemic or pink and suffused with SVC obstruction
- Face
- Plethora (polycythaemia or SVC obstruction)
- Eyes: anaemia
- Mouth: Central cyanosis
- Neck
- JVP (raised >4 cm) in cor pulmonale
- Palpate lymph nodes
- Tracheal deviation
- Cricoid–suprasternal notch distance (
- Chest
- Palpates
- Palpates apex beat
- Measures chest expansion (6–8 cm is normal) at three places on the anterior and three on the posterior chest
- Percusses
- Percusses three areas on right/left side
- Auscultate
- Breath sounds
- Normal breathing pattern expiration more prolonged than inspiration 2:1
- Vesicular: Normal breath sounds and are soft and low pitch with a more blowy quality.
- Bronchial breath: harsh high pitch and equal duration inspiratory and expiratory phases. Sounds like listening over one's trachea. They are abnormal when heard on the chest surface. They usually suggest consolidation
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- Reduced air entry suggests pathology
- Collapse, consolidation
- fibrosis, pleural thickening
- Hypoventilation if bilateral
Reduced breath sounds - Hypoventilation
- Pleural effusion
- Pneumothorax
- Added sounds
- Pleural rub: fine crackling noise with respiration
- Rhonchi/Wheeze suggests asthma or COPD
- Fine crepitations "crackles" or rales can suggest pulmonary oedema, resolving consolidation or infection or pulmonary fibrosis
- Coarser crackles heard with Bronchiectasis or cystic fibrosis
- Breath sounds
- Auscultate at three areas right and left side of chest on the anterior and posterior chest and over axillae to listen for right middle lobe signs
- Auscultate for vocal fremitus: Say "99" and is increased over consolidation to the point that one gets "whispering pectriloquy"
- Palpates
- Elsewhere
- Palpates shins or ankles for peripheral oedema
- Extras
- Ask if you can measure the patient's PEFR (ensure you can do this properly)
- Look at observations chart for O2 sats and temperature and respiratory rate
- Finishing
- Thank patient and offers to help patient get dressed
- Wash hands and think about how to present your findings
- Present Findings and suggest a differential diagnosis
- Suggests appropriate investigations and management
Background Information
| Pathology | Aetiology | History/Inspection | Mediastinum | Palpation/Percussion | Auscultation |
|---|---|---|---|---|---|
| Consolidation | Lobar Pneumonia | Dyspnoea, Cough, fever, Pleurisy | Central and reduced movement same side | Dull to percussion, Increased Tactile fremitus and reduced expansion | Bronchial breathing, Added sounds, wheeze and creps and increased vocal resonance (whispering pectoriloquy) |
| Collapse of lobe or lung | Occluded bronchus | No shift | Dull over pathology | Bronchial | Reduced same side |
| Pleural Effusion | Fluid in pleural space | Progressive breathlessness, fever, weight loss | Central or away from pathology if > 1 L. Reduced movement affected side | Stony Dull over pathology, Reduced Tactile fremitus, | Reduced vesicular breath sounds. Crackles at upper edge with pleural friction rub |
| Asthma | Bronchospasm and mucus plugs | Central | Resonant | Exp Wheeze | Reduced Vesicular breath sounds bilateral, Ominous silent chest |
| COPD | Chronic cough, wheeze, smoker, distressed | Central | Resonant | Exp Wheeze | Decreased vesicular sounds, exp wheeze |
| Pneumothorax | Air in Pleural space | Dyspnoea, wheeze, distressed | Central or towards PTX and reduce movement same side | Hyper/Resonant, Reduced Tactile fremitus | Reduced Vesicular breaths, added sounds |
| Tension Pneumothorax | Air under pressure in Pleural space | Dyspnoea, wheeze, distressed, hypotenisve, cardiac arrest | Hyper/Resonant | Reduced | Reduced vesicular breath sounds, affected side |
| Pulmonary Fibrosis | Air under pressure in Pleural space | Away from PTX | Hyper/Resonant | Reduced | Reduced affected side |