Respiratory Exam

1 WIPE
2 Explain examination, obtain consent and ask patient’s name
3 Ask if patient is comfortable to lie at 45 degrees.
4 Expose (Ideally from head to waist)
## Before chest: general appearance, hands, pulse and BP, eyes, mouth, neck.
5 Inspect general appearance of the patient;
Comment on:  Comfortable?
 Sick?  Oxygen
 Position of patient  IV cannula, catheter.
 Conscious?  Respiratory distress
 Inhalers?  Sputum box

6 Hands: (6 things)
 Clubbing  Tobacco staining
 Pallor  Rheumatoid signs
 Cyanosis  Flapping tremors

7 Pulse: (3 things) at least 15 seconds  Respiratory rate with fingers on radial

 Rhythm pulse
 Rate
 Volume/character
8 Blood pressure and temperature
9 Eyes: (2 things)
 Jaundice
 Pallor (use two thumbs)

10 Mouth: (3 things)
 Central cyanosis
 Glossitis
 Tonsillitis

11 Neck: (4 things)
 Tracheal tug
 JVP: differentiate from arterial and measure length
 Lymphadenopathy
12 Anterior chest inspection: (4 things) go to the foot of  Chest movement
the BED!!!!!  Scars (even lateral sides): hands on waist
 Chest contour  Dilated veins
 Type of breathing

13 Ask for PAIN:

Palpation: (5 things)  Palpable second heart sound
 Trachea  Tactile vocal fremitus 3 times each the
 Apex: localize axilla
 Chest expansion: 3 times
14 Percussion:
 above clavicles,
 On clavicles
 Below clavicles thrice
 Mid axillary line twice
15 Auscultate with diaphragm Describe findings as: e.g.
Ask patient to breath via mouth deeply in and  There is normal vesicular breathing all
out over the chest except left upper zone
 Above clavicles where there is bronchial breathing.
 Below clavicles  There is reduced air entry and breath
 At nipples sounds at the left upper zone of the chest,
 then lateral normal at the other zones.
Alternating sides  There are fine crackles at left upper zone
Whispered pectorilquy too.
Ask patient to cough if there is a wheeze  There is increased vocal resonance at
Auscultate vocal resonance at TVF sites affected site

BACK!!!!!!!!!

16 Inspect the back

17 Chest expansion and TVF at back

18 Percuss back
19 Auscultate back
 Type of breathing
 Air entry and breath sounds
 Added sounds
 Vocal resonance
20 Palpate abdomen for hepatomegaly
21 Complete exam by lower limb edema, PEFR, sputum examination.
22 Thank and cover patient.
23 Summary:
24 Discuss causes, investigations and complications of
Fibrosis, consolidation and other clinical diagnosis of the chest.
 Discussion

1 Chest contour depression +/- tracheal deviation Lobar fibrosis

↓Chest expansion
↓Percussion note
↑Vocal resonance
Bronchial breathing +/- crackles
2 ↓Chest Expansion Consolidation
↓Percussion note
↑Vocal resonance
Bronchial breathing +/- coarse crackles
Whispering pectoriloquy
Central trachea and no contour change
3 ↓Chest expansion Pleural effusion
↓Percussion (stony dull)
↓Vocal resonance
↓Air entry +
Central trachea except if massive
4 Clubbing Bronchiectasis
Wheeze
Coarse crackles that change with coughing
5 +/-Cyanosis COPD
+/- Respiratory distress and tachypnea
Inhaler
Barrel chest
Wheeze
↓Percussion note
Tracheal tug
6 JVP, palpable S2 Pulmonary HTN
Investigations:
General: Specifc:
 CBC: anemia of chronic disease and  CXR and O2 sats
polycythemia of COPD  Sputum analysis and culture
 Total WCC: infections  HRCT
 ESR and CRP  Spirometry
 RFT  Bronchoscopy
 Urine analysis  ABG
 Biopsy
 LUNG FIBROSIS
Causes  Lung function tests: Restrictive pattern:
↓FEV1 and ↓FVC, normal FEV1/FVC
Apical: TRASH_TOE  Lung Biopsy is definitive: CT/US
 TB guided, bronchoscopic. Best is
 Radiation Tx surgical biopsy.
 Ankylosing
spondylitis/psoriasis/ABPA
 Sarcoidosis Treatment:
 Histoplasmosis 1. Non pharmacological:
 Trauma  Preventing and modifying risk
 Occupational lung diseases e.g. factors
silicosis (except asbestosis)  Exercise
 Extrinsic allergic alveolitis  Avoid smoking
 Chest physiotherapy
2. Pharmacological:
Lower lobe Fibrosis: CIA_BADAS  Steroids if indicated
 Connective tissue disease: almost all  O2 therapy
 Idiopathic pulmonary fribrosis  Palliatives
 Asbestosis  Opiates, etc
 Bronchiectasis 3. Surgery: lung transplant
4. Tx COPD
 Aspiration pneumonia
 Drugs: eg MTX, Amiodarone
 Asbestosis
 Scleroderma PULMONARY HTN >25mmHg
Investigations:

Middle lobe: almost same as upper lobe  CXR

 ECG
 Cardiac cath
 Echo

Investigations TX:

1. General  Vasoactive agents: eg CCBs,

2. Specific Prostacyclines, Bosentan, Viagra.
 Pulse Oximetry  Inotropes and diuretics
 Chest Xray: opacities: ground glass or  O2 therapy
honeycomb. Highly nonspecific and  Avoid pregnancy
maybe normal  Tx underlying cause
 HRCT scan: Very specific, less  Lung transplantation
sensitive
CONSOLIDATION PLEURAL EFFUSION
Causes
Causes Transudates
 ↑venous pressure (Left heart failure, fluid
Lobar pneumonia overload, constrictive pericarditis, PE)
Aspiration  ↓Plasma proteins (Cirrhosis, Nephrotic
Hemorrhage syndrome, malabsorption)
Pulmonary edema Exudates:
Malignant consolidation: lung cancer
 ↑Capillary permeability: infection,
Inflammations, malignancies.
Investigations:  Pneumonia, TB, Pulmonary infarction (PE);
 General  RA, SLE;
 Specific
 Bronchial cancer, mets, mesothelioma,
 O2 sats
 CXR lymphoma, etc.
 Sputum analysis Investigations:
 CT General
 Broncho alveolar lavage Specific:
 Biopsy if not yet diagnosed  O2 sats
 CXR (costophrenic blunting if small/air
Management: fluid levels)
General:
 USS and for aspiration
 O2 supplementation
 Aspiration: differentiate exudate from
 Pain relief
transudate
 Pleural biopsy: Thoracoscopic or CT
Specific:
guided
 Antibiotics: pneumonia
 Other investigations according to
 Bronchoscopy hemorrhage
suspected etiologies
 Diuretics for Left HF
 Chemo/radio +- surgery for cancer
Management:
Non pharmacologic: General:
 Patient education  O2 supplement
 Smoking and other RF avoidance  Antipyretics and pain killers etc
 Exercise Specific:
 Good nutrition and hygiene  Drainage: same way as dx tap or chest
tube
 Pleurodesis with talc if
recurrent/malignant
 Intrapleural altepase: empyema
 Surgery: persistent collections with
thickened pleura
BRONCHIECTASIS COPD
Causes Causes
 Tobacco smoke
 Congenital: CF, Young’s syndrome,  α1-Antitrypsin deficiency
primary ciliary dyskinesia,  Environmental factors (e.g., second-
Kartagener’s syndrome. hand smoke)
 Post-infectious: Pneumonia, TB, HIV,  Chronic asthma
pertussis, measles.
 Others:
 Bronchial obstruction, UC, RA, ABPA, Investigations:
idiopathic
General
Investigations:
Specific:
General
 Spirometry: obstructive pattern
Specific:  Chest radiograph (CXR): nonspecific, for
exacerbations
 Sputum culture  α1-antitrypsin levels
 CXR (tramline and ring shadows)  Arterial blood gas (ABG)—chronic PCO2
 HRCT retention, decreased PO2.
 Spirometry (obstructive pattern), Management.
assess for reversibility
 Bronchoscopy for hemoptysis site, General mgt:
obstruction etc.  Stop smoking
 Specific for etiology eg CF sweat test  Diet + supplements
 Vaccination
 Exercise
Management:  Prevent depression
 Diuretics for edema
 Antibiotics for acute
exacerbations,commonly Specific:
pseudomonas: ciprofloxacin.  SABA/SAMA
 Bronchial hygiene is very important.  LABA/LAMA
 Hydration
 Inhaled corticosteroids
 Chest physiotherapy (postural
 LTOT (Long term O2 therapy)
drainage, chest percussion) to help
remove the mucus
 Inhaled bronchodilators and steroids
 surgery if severe hemoptysis