the respiratory system examination dr mike henry dr claire bowker dept of respiratory medicine leeds...

The Respiratory System Examination

Dr Mike HenryDr Claire Bowker

Dept of Respiratory MedicineLeeds General Infirmary

Major Symptoms of Respiratory Disease

• Cough

• Sputum production

• Dyspnoea

• Haemoptysis

• Wheeze

• Chest pain - pleuritic

Cough• Larynx / Pharynx – harsh and painful• Trachea – harsh, dry and painful / productive• Bronchitis - paroxysmal / productive

AcuteChronic

• Carcinoma – short / dry - haemoptysis• Bronchiectasis – productive purulent sputum• Pneumonia – painful and productive• Pulmonary Oedema – dyspnoea/ orthopnoea/ PND• Fibrosing alveolitis – dry / short / persistent

Sputum

• Amount

• Character

• Viscosity

• Taste or odour

Dyspnoea

• Dyspnoea associated with increased work of breathing

• Dyspnoea associated with increased pulmonary ventilation

• Dyspnoea associated with weakness of muscles of respiration

• Dyspnoea associated with multiple factors

Acute Onset Dyspnoea

Sudden Rapid(minutes) (hours – days)

Pneumothorax Acute asthmaSevere acute asthma Pulmonary oedemaPulmonary embolism PneumoniaLaryngeal oedema Acute bronchitisForeign body Allergic alveolitisPulmonary oedema (orthopnoea / PND)

Gradual Onset Dyspnoea

• Onset days – weeks – months

Pleural effusion

Chronic asthma

Fibrosing alveolitis

Tuberculosis

Chronic bronchitis

Bronchial carcinoma

Slow Onset Dyspnoea

• Onset months – years

Pleural fibrosis

Emphysema

Pneumoniconiosis

SarcoidosisChronic broncitis

Ankylosing spondylosis

Haemoptysis

Type and degree

• Frank – whole blood / clots Carcinoma / PE / Bronchiectasis / TB

• Blood Stained – blood/sputum mixedSuppurative pneumonia / Carcinoma

• Blood Streaked – streaks or flecksCarcinoma / chronic bronchitis

• Rusty – degraded HbPneumococcal pneumonia

Aetiology of Wheeze

Chest PainSite CharacterRadiation SeverityDuration Frequency and

periodicityAggravating factors Relieving factors

Associated phenomena

• Upper reterosternal – tracheitis

• Reterosternal – oppressive similar to cardiac pain / not related to exertion

• Pleuritic – stretching of inflammed parietal pleura

The Physical Examinationfrom the end of the bed - Inspection

• Patient comfortable ? / Supine 45• Look around the bed• Measures of respiratory compromise

RESPIRATORY RATE Use of accessory muscles

• Audible sounds• Patient in pain• Cyanosis• Oedema• SVCO

Palpation• Hands

Finger clubbingCyanosis

Signs of CO2 retention• Eyes

Signs of CO2 retentionAnaemiaHorners syndromePapilloedema

The Laying on of HandsPalpation

• The NeckScalene lymph nodesJVP – jugular venous pressureTrachea

CentralTracheal tug

Thyroid• Skin

Erythema nodosumMetastatic carcinoma nodulesLupus pernio

Chest wall• Symmetry of chest wall movements during

tidal and deep breathing• Chest expansion (2-4 cms) Two levels ?• Significance of reduced chest wall

movements• Anteropostero:lateral diameter = 5:7• Pectus excavatum / Carinatum /

kyphoscholiosis• Thoracic operations / thoracoplasty

Chest wall

• Significance of reduced chest wall movements

• Pleural Effusion: reduced unilateral• Consolidation : reduced unilateral• Collapse of lobe: reduced unilateral• Pneumothorax: reduced unilateral• COPD:reduced bilateral• Asthma: reduced bilateral• Pulmonary fibrosis: reduced bilateral

PercussionWhere to percuss

How to percuss - technique

• Normal: Resonant• Impaired: consolidation / collapse / fibrosis• Dull: consolidation / collapse / pleural thickening• Stony dull: fluid = pleural effusion• Hyperresonant : pneumothorax• Typanic: hollow viscus

• Vocal tactile fremitus• Vocal resonance

Percussion

Auscultation

• Normal breath sounds produced by air through larynx / vocal cords vibrations

• Vibrations transmitted through airways to the chest wall rustling sound = Vesicular

• Diminished: airflow obstruction / pneumothorax / pleural effusion

• Bronchial breath sounds: consolidation, fibrosis or collapse: resemble breath sounds heard over larynx

Auscultation

Added sounds

Wheezes – passage of air through narrow bronchi

Usually expiratoryIf inspiratory – mucosal oedema clear with coughDescribe siteFixed low pitch – STRIDOR – upper

airflow obstruction

Added soundsCrackles

Explosive reopening of small airways occluded during expiration

Fine crackles: pulmonary oedema / consolidation – usually inspiratory

Course crackles: pulmonary fibrosis / bronchiectasis

Plueral rub / pleural click

Interstitial Lung Disease – CFA Bilateral course / velcro bibasal crackles

Pleural Effusion

• Chest expansion - reduced

• Percussion - stony dull

• Breath sounds - absent or decreased

• Added sounds - none

• Vocal resonance - absent or decreased

Consolidation 

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Consolidation

• Chest expansion - reduced

• Percussion - dull

• Breath sounds - bronchial

• Added sounds - crackles

• Vocal resonance - increased (whispering pectorilouy)

ATAELECTASIS - Total right lung collapse

Collapse left lower lobe – The Sail Sign

Collapse / Atelectasis lobe or lung

• Chest expansion - reduced

• Percussion note - dull

• Breath sounds - absent or diminished

• Added sounds - none / crackles or wheeze

• Vocal resonance - absent / decreased

Pneumothorax

• Chest expansion - reduced

• Percussion - hyperresonant

• Breath sounds - absent or decreased

• Added sounds - none, occasionally click

• Vocal resonance - decreased