Respiratory examination

In medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem (dyspnea (shortness of breath), cough, chest pain) or a history that suggests a pathology of the lungs. It is very rarely performed in its entirety or in isolation, most commonly it's merged with the cardiac examination.

Position/Lighting/Draping

Position - patient should sit upright on the examination table. The patient's hands should remain at their sides. When the back is examined the patient is usually asked to move their arms forward (hug themself position) so that the scapulae are not in the way of examining the upper lung fields.

Lighting - adjusted so that it is ideal. Draping - the chest should be fully exposed. Exposure time should be minimized.

The basic steps of the examination can be remembered with the mnemonic PIPPA:

• Position
• Inspection (for example, "normal effort")
• Palpation (for example, "no tenderness to palpation", "fremitus WNL")
• Percussion (for example, "clear to percussion bilaterally" or "CTP B")
• Auscultation (for example, "clear to auscultation bilaterally" or "CTA B"; "no R/R/W" or "no rhonchi, rales or wheezes")

Inspection of the fingers for cyanosis or clubbing is sometimes included in the respiratory examination.

Inspection

Inspection or observation involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. It is best to count the respiratory rate under pretext of some other exam, so that patient does not sub consciously increase his baseline respiratory rate. An acidotic patient will have more rapid breathing to compensate known as Kussmaul breathing. Another type of breathing is Cheyne-Stokes respiration, which is alternating breathing in high frequency and low frequency from brain stem injury. It can be seen in newborn babies which is sometimes physiological (normal). Also observe for retractions seen in asthmatics. Retractions can be supra-sternal, where the accessory muscles of respirations of the neck are contracting to aid inspiration. Retractions can also be intercostal, there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. This is a sign of respiratory distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for shifted trachea or one sided chest expansion, which can hint pneumothorax.

• Tracheal deviation (can suggest of tension pneumothorax)

Chest wall deformities

• Kyphosis - curvature of the spine - anterior-posterior
• Scoliosis - curvature of the spine - lateral
• Barrel chest - chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD
• Pectus excavatum - sternum sunken into the chest
• Pectus carinatum - sternum protruding from the chest

Signs of respiratory distress

• Cyanosis - person turns blue
• Pursed-lip breathing - seen in COPD (used to increase end expiratory pressure)
• Accessory muscle use (scalene muscles)
• Diaphragmatic paradox - the diaphragm moves opposite of the normal direction on inspiration; suspect flail segment in trauma
• Intercostal indrawing
• movement of chest-chest movement decreases on the affected side
• jugular venous pulse-indicates right heart failure

Palpation

For palpation, place both palms or medial aspects of hands on the posterior lung field. Ask the patient to count 1-10. The point of this part is to feel for vibrations and compare between the right/left lung field. If the patient has a consolidation (maybe caused by pneumonia), the vibration will be louder at that part of the lung. This is because sound travels faster through denser material than air.

If there is pneumonia, palpation may reveal increased vibration and dullness on percussion. If there is pleural effusion, palpation should reveal decreased vibration and there will be 'stony dullness' on percussion.

• Tracheal deviation - check whether trachea is in centre line.
• Tactile fremitus - the patient says boy-O-boy or ninety-nine, whilst physician sense with ulnar aspect of hand for changes in sound conduction.
• Respiratory expansion - check whether expansion is equal
• Location of apex beat - check if there has been deviation of heart

Percussion

On percussion, you are testing mainly for pleural effusion or pneumothorax. The sound will be more tympanic if there is a pneumothorax because air will stretch the pleural membranes like a drum. If there is fluid between the pleural membranes, the percussion will be dampened and sound muffled.

Middle finger strikes the middle phalanx of the other middle finger. The sides of the chest are compared.

• dullness indicates consolidation
• hyper-resonance (as can be simulated by percussing the inflated cheek) suggests a pneumothorax (can be related to COPD or a pleural effusion)
• diaphragmatic excursion - normal is 3 to 6 cm.

Auscultation

Lung auscultation is listening to the lungs bilaterally at the anterior chest and posterior chest. Wheezing is described as a musical sound on expiration or inspiration. It is the result of narrowed airways. Rhonchi are bubbly sounds similar to blowing bubbles through a straw into a sundae. They are heard on expiration and inspiration. It is the result of viscous fluid in the airways. Crackles or rales are similar to rhonchi except they are only heard during inspiration. It is the result of alveoli popping open from increased air pressure.

• Inspiratory crackles (decompensated congestive heart failure)
• Expiratory wheezes (asthma, emphysema)
• Stridor and other upper airway sounds
• Bronchial vs. vesicular breath sounds
• Appropriate ratio of inspiration to expiration time (expiration time increased in COPD)

Vocal fremitus (Is performed)

• Egophony
• Whispered pectoriloquy

External links

• Respiratory exam - University of Florida
• Exam of the chest - University of Florida
• Respiratory exam - Respiratory Exam
• Lung sounds online - Emory University School of Medicine