Station 1: Respiratory Examination
WIPER Q (wash hands, introduce yourself, seek permission to examine, expose the patient adequately to waist, reposition the patient to 45 degrees, ask if the patient is comfortable/has any pain)
Eyeball the patient from the end of the bed:
- Patient: well/unwell, in pain?, distressed/comfortable at rest, breathless, colour, cachectic, access muscle use, chest wall and spine deformity, stridor/wheeze/cough, Cushingoid, pursed lips, scars of past surgery/chest drain/radiotherapy, chest drain, photosensitive skin rash
- Ask patient to take deep breath in: is chest wall movement symmetrical. Ask them to do this several times if unsure whether movement is assymetrical or not. Look also at depth of inspiration
- Ask the patient to cough
- Take RR from end of bed and breathing pattern
Inspect the surroundings: sputum pots, inhalers, nebulisers, oxygen tubing, peak flow meters, spacers, antibiotics, steroids
Signs of resp distress (occurs if high negative intrapleural pressures needed to generate air entry):
- Nasal flaring
- Tracheal tug (pulling of thyroid cartilage towards sternal notch in insp). Descent of trachea with insp limiting airflow.
- Use of access muscles
- Intercostal, subcostal, sternal recession
- Pulsus paradoxus
- Paradoxical respiration: abdomen sucked in with insp in diaphragmatic paralysis
- Temperature and colour and cap refill
- Clubbing: look at finger from the side
- Tar staining
- Yellow nails, nail fold vasculitis
- Wasting of intrinsic muscles (T1 lesions eg. Pancoasts tumours)
- Palmer erythema
- Fine Salbutamol Tremor. Ask patient to hold hands out.
- CO2 retention flap (asterixis): wrists dorsiflexed and fingers spread “hold arms out for me and spread fingers. close your eyes. Ideally I would like to hold this for 30secs”
- Palpate wrist for tenderness (HPOA)
- Look for evidence of Rheumatoid arthritis including nodules, scleroderma, dermatomyositis (gottrans papules)
- Thin, bruised skin (steroids)
Resp Causes of Clubbing:
- Lung Carcinoma (especially SCC, usually not small cell)
- Chronic suppurative lung disease:
- Pleural and mediastinal tumours eg. mesothelioma
- Pulmonary fibrosis eg. cryptogenic fibrosing alveolitis
- Cryptogenic organising pneumonia
Radial Pulse: rate and rhythm and character. Paradoxical: resp distress. Bounding: CO2 retention.
RR: time for 30 secs (N= 14-16) and pattern of breathing (if not assessed already at the end of the bed)
- Hyperventilation may be fast (tachypnoea >20) or deep (hyperpnoea, increased tidal vol). May cause resp alkalosis,hence paraesthesiae with or without muscle spasm (reduced Ca2+). NB: the anxious patient in A+E with hyperventilation and resp alk may actually be presenting with aspirin OD.
- Kussmaul respiration: deep sighing breaths in severe metabolic acidosis (helps to blow off CO2).Eg. DKA, renal failure.
- Neurogenic hyperventilation due to pontine lesions
- Hyperventilation syndrome: panic attacks etc
- Cheyne-Stokes breathing: breaths get deeper and deeper then shallower in cycles with episodic apnoea. Caused by brainstem lesions or compression eg. stroke, raised ICP. It is enhanced by opioids. If the cycle is long eg. 3 min, the cause may be a long lung-to-brain circ time eg, in chronic pul oedema or reduced CO.
JVP (increased in cor pulmonale) and neck eg. photosensitive skin rash, neck size
Eyes: Conjunctival pallor, Horners (ptosis, miosis, anhydrosis, enopthalmus eg. pancoasts tumour)
Face: Lupus pernio, malar rash, flushed, cushingoid, scleroderma features, facial swelling of SVCO obstruction
Mouth: central cyanosis, oral candida, microstomia (systemic sclerosis)
Lymph nodes from behind in fluid movement with patient sat forward: submental, submandibular, pre and post auricular, occipital, ant and post cervical chain, ant and post triangles, supraclavicular, axillary. Enlarged due to chest malignancy/TB.
Back: kyphoscoliosis, evidence of ankylosing spondylitis, scars on back. NB: a protuberant abdomen and abnormal posture may indicate ankylosing spondylitis
- Chest wall deformity eg. pectus excavatum (funnel or sunken chest)/carinatum (pigeon chest), barrel chest (AP diameter bigger, tracheal descent and chest expansion reduced) in chronic hyperinflation eg. COPD/asthma, scoliosis (lateral bending), kyphosis (forward bending, humpback, increased AP thoracic spine curvature). Can all restrict lung movement.
- Scars: ask pt to raise arms. Eg. phrenic nerve crush, median sternotomy, ant. thoracotomy
- Access muscle use: SCM, platysma, infrahyoid, scalenus, trapezius
- Assymetry of chest wall expansion: ask pt to take deep breath.
- Chest drain sites/scars
- Skin lesions eg. radiotherapy mark on chest
- SVCO- prominent veins on the arms, neck and upper chest
Pectus excavatum: Often asymptomatic but can cause displacement of the heart to the left and restricted vent capacity with or without mild air trapping. Associations: scoliosis, Marfans, E-D syndrome. Common. Appears during adolescent growth spurts. Exercise intolerance is the main symptom (from heart compression).
Pectus carinatum: prominent sternum from lung hyperinflation while the bony thorax is still developing eg. in chronic childhood asthma. Often seen with Harrison’s sulcus, a groove deformity caused by indrawing of lower ribs at the diaphragm attachment site.
Palpate praecordium: “I am now going to examine your chest with my hands”
- Trachea: feel in sternal notch. Is it deviated? Warn pt that it might be uncomfortable. “Trachea is central”. Slight deviation to the R is normal. Place a finger either side of the trachea and judge whether the distance between it and the sternomastoid tendons are equal on both sides. Assess crico-sternal distance in fingerbreadths, <3cm is hyperexpansion
- Chest expansion: ask patient to “breathe all the way out, now a deep breath in”. “Chest expansion is symmetrical and not reduced”
- Upper with hands flat either side of the midline.
- Lower: anchor with the fingers and leave thumbs together but free-floating. Note distance of thumbs to midline- is it the same?. <5cm on deep inspiration is abnormal. Decreased expansion implies ipsi pathology.
- TVF: Ask patient to repeat 99 each time they feel your hand while palpitating the chest wall with the ulnar border of your hands over different segments including axilla. “ I will check for VR instead when auscultating”. Increased in consolidation but less sensitive than VR.
- Apex beat: displaced if scoliosis, LV dilatation, altered position of mediastinum. Impalpable if COPD/dextrocardia/pleural effusion.
- Feel for RV heave suggestive of RV hypertrophy (RV pressure overload due to pulmonary hypertension) and palpate pulmonary area for palpable S2 suggestive of pulmonary hypertension.
Percuss Praecordium: tap middle of clavicles then 2 in chest then axilla. Strike the middle phalanx of the middle finger of the left hand with the middle finger of the right hand. Finger in IC space. “Chest is resonant to percussion throughout”
Cardiac dullness over LHS. Liver dullness extends up to 5th rib R mid-clav line: if below this is resonant then chest is hyperexpanded (asthma, COPD).
- Ask patient to “take some deep breaths in and out through your mouth”. Listen in apices with bell, then chest with diaphragm and axilla comparing left with right. “Breath sounds are vesicular with no added sounds”. Quality, intensity, added sounds.
- VR: ask pt to say 99 each time they feel the stethoscope. “VR is normal”. If increased resonance heard (consolidation suspected), repeat with asking pt to whisper 99- if clearly heard this is termed ‘whispering pectoriloquy’
- Listen to P2.
- If hear creps- ask patient to cough. Do the creps clear with coughing? Ask the patient to lean forward- do the creps disappear/reduce on leaning forward?
Normal vesicular breath sounds have a rustling quality. Insp is more prolonged than exp
Bronchial breathing: hollow quality, gap between insp and exp. The noise heard during insp and exp is equally long but separated by a short silent phase. When lung tissue has become firm/solid. Associated with increased TVF and VR, whispering pectoriloquy.
- Localised fibrosis
- Above a pleural effusion
- Next to a large pericardial effusion (Ewarts sign)
Healthy lung attenuates high-freq notes. Consolidated lung transmits high freq and spoken word becomes bleating (VR). Whispered speech is high-pitched and is clearly transmitted in consolidated lung.
Reduced Breath Sounds:
- Pleural effusion
- Bronchial obstruction
- Wheeze (rhonchi): caused by air expired through narrowed airways.
- Monophonic (single note, single large airway obstruction) eg. tumour
- Polyphonic (multiple notes, narrowing of many small airways of different calibre) eg. asthma, COPD
- LVF (cardiac asthma)
- Crackles (creps): caused by reopening, during insp, of small airways which have been occluded during exp. Check if they disappear on coughing- if so they are insignificant.
- Fine and highpitched: distal air spaces eg. pul oedema, fibrosing alveolitis
- Coarse and lowpitched and loud: proximal eg. bronchiectasis
- Early: small airways disease, diffuse airflow limitation eg. COPD
- Late/pan-insp: disease confined to alveoli eg. pul oedema, fibrosis, bronchiectasis
- Pleural rub: caused by movement of the visceral pleura over parietal pleura, when both surfaces roughened eg. inflammatory exudate. Creaking/groaning. Causes: adj pneumonia, pulmonary infarction
- Stridor – high pitched insp noise. Cause: laryngeal disease, localised narrowing of large airways
Examine front and back of chest. You may wish to examine the back first in case you run out of time and miss the key signs.
Check for sacral and ankle oedema. Check legs for DVT.
Thank you very much that completes my examination. Wash hands. Put stethoscope behind back and present findings.
To complete the examination (select appropriately depending on findings so far and time left):
- Perform the examination on the back (cross arms to displace scapulae)
- Examine sputum pots
- Oxygen sats
- Ankle oedema (cor pulmonale, RH failure)
- Axillary LNs
- Temperature chart, BP
- Liver edge in COPD
Written by Dr Sarah Kennedy using the resources outlined in the references section of this PACES website