Respiratory Examination

Once you have done your initial introductions and examination from the end of the bed described in the examinations page you can then move onto more specific examination.

Now we can approach the patient and start to take a good close look at them. As with both abdominal and cardiovascular examination we always start with the patients hands. As well as just looking one can also tell a lot from the feel of those hands:

  • Are they warm or cold? A cold septic patient is often a sicker one than a warm septic patient.
  • If they are cold do they appear peripherally shut down? Are their hands mottled looking? What is their capillary refill time?
  • Do they feel sweaty or clammy?
  • Do their hands appear pale or anaemic looking?
  • Are there any signs of a chronic smoking habit i.e. nicotine staining around the fingers.
  • Are their finger nails clubbed? Always hold the hands up to eye level if possible or get down to their level to look at the nails side on which is the best angle from which to judge nail clubbing.
  • Is there any sign of a tremor? This could be caused by the bronchial dilator drugs we are giving them or it could be that they are starting to develop a carbon dioxide retention flap which can occur once a patient begins to become encephalopathic.

We then move our examination up the arm. I always make a point of looking at the arm as I move up so that I do not forget anything. At this stage we need to check the radial pulse and we are checking it for presence, rate, rhythm and volume. A very tachycardic patient may be septic, or it could just be the drugs which we give them which are making their heart beat faster. A patient with a bounding pulse may be showing early signs of carbon dioxide retention. As with all systems when you have two of something you should always compare and contrast. So you should check the other hand to see if there are any differences and you should compare the radial pulses on both sides.

Moving further up the arm as you go higher this is a visual reminder to check the blood pressure. The heart and lungs are interconnected and what affects one can very well affect the other. The patient in crashing pulmonary oedema for example may very well have a very high blood pressure that may need some controlling with nitrates.

We then move up further and into the patients’ neck. Here you will want to check and observe a number of things:

  • The position of the trachea needs to be established. Is it central? Put one finger either side of the trachea to establish whether it is equidistant from the ends of the clavicles. It may be deviated one way or another either because of a pneumothorax, which it will deviate away from or because of collapse, which it will deviate towards.
  • Is the patient using his accessory muscles to help him breathe?
  • The jugular venous pressure should also be examined. This is a skill which takes a little practice, but you can make the task much easier if you first identify your landmarks. The patient needs to be seated at a 45 degree angle looking slightly away from you with their head resting on a pillow. You then need to identify the sternocleidomastoid muscle which runs from behind the ear down to the manubrium. If you struggle to identify the muscle ask the patient to lift their head slightly off the pillow. This will make the muscle stand out. It attaches at its inferior end via a sternal attachment and a calvicular attachment.
  • These form a triangle, and it is in this triangle that you will look for the pulsation of the jugular vein. A normal JVP is about 4-5 cm’s above the angle of Louis which equate to a centimetre or two above the clavicle. If you cannot see the JVP then this should not be of concern. If, however, the JVP seems higher then this then it may be worth remarking upon as a possible cause of the patients problems. The JVP is a direct reflection of the right sided pressures in the heart and if these are elevated it could be due to a degree of heart failure. Armed with this information treatment can go down one particular path.

The patients face is where we turn our attention to next.

  • Do they show any signs of central cyanosis? Are their lips blue? Ask them to touch the roof of their mouth with the tip of their tongue. If that appears blue underneath then they are very cyanosed and their oxygen levels are very low.
  • Do they appear dehydrated? Do the oral membranes look moist or dry?
  • What is the condition of their teeth? Oral dentition can often be a clue as to how well they look after themselves generally.
  • Do their eyes appear jaundiced or anaemic?

The patient’s chest then becomes the area we examine next. A visual inspection is what we do first. The respiratory, cardiovascular and abdominal systems are all examined using the process of inspection, palpation, percussion and auscultation. So we first need to simply look at the chest wall for any indications of any problems we need to be aware of:

  • First look at both their respiratory rate and pattern. Are they breathing quickly or slowly and if so can you speculate why this might be. It may be that they are breathing quickly due to pain, or they may be septic, so trying to compensate for their acidosis. They may be breathing too slowly because they are compromised neurologically.
  • Are they utilising accessory muscles to breathe? Are they abdominal breathing, that is utilising their abdominal muscles to help them suck as much air into their lungs as is possible?
  • Are there any scars or sinuses which may have some impact on their respiratory function? Do you see any drains?
  • Does the chest seem to be rising and falling symmetrically? Is there any area on the chest that might be suggestive of a flail chest, an area moving independently of the rest?
  • What is the overall shape of the chest? Are they barrel chested or pigeon chested?

Then we can palpate the chest once we have done our inspection.

This is a fairly simple process when doing an examination of the chest. You are mainly checking for equal chest expansion. One simply puts ones hands on the chest with one on each side and ask the patient to take a deep breath in. You then note whether the chest seems to rise and expand equally.

At this point you can also try to ascertain if there is reduced tactile vocal fremitis. If you suspect an area of some consolidation then when you put a hand over it and ask the patient to say 99 for example you are more likely to feel them say it than over a non consolidated area.

Percussion of the lung fields comes next. Correct percussion technique is not difficult but it might take some practice before you feel completely confident when doing it. The non-dominant hand is placed on the patient’s chest. Then all put the 2nd finger are lifted off the chest. The entire length of the 2nd finger should be kept in contact with the chest. It is important to keep the other fingers off the chest wall so that you do not dampen any sound you may elicit. The 2nd finger of the dominant hand then acts as a hammer to strike the distal phalangeal joint of the other hands 2ndfinger. You strike this with the tip of the finger which will then create a nice sound for you to compare all over the chest wall. It is important to Percuss over the entire chest wall from top to bottom, comparing both sides, noting any dullness or hyper-resonance as you go. Be aware that you may get dullness where there are other structures involved such as over the liver for example.

Once this is done it is time to put your stethoscope over the patient’s chest. When doing so make sure that you use the diaphragm and that you press firmly. You should leave a slight imprint on the patient’s chest when you do so. Again make sure that you cover the whole of the chest and be aware of which lobe you are likely to be listening too when you move about. Because the lobe divisions are oblique you need to be aware that from the front on the left side you are mainly listening to the upper lobe. From the back on the left side, at the top of the shoulders you are still listening mainly to the upper lobe but the rest of the left side at the back will be the lower lobe. Much the same on the right side but here you have three lobes to think about. On the front the upper part is mainly upper lobe whilst the lower part of the chest will be the middle lobe. It is only when you move around to the back that you will begin to encounter the lower lobe at the lower end of the right side of the back.

So what are you listening for?

  • Breath sounds or the absence of breath sounds. You should be able to hear breath sounds throughout the chest, and they should be of equal volume and character. If they are reduced this may be due to collapse, consolidation or effusion. Complete absence may be suggestive of a pneumothorax.
  • Added sounds. Two of the most commonly heard added sounds are the wheeze and the crackles. A wheeze is created because of narrowed airways, which may be due to asthma, COPD or severe heart failure for example. Crackles can be fine or coarse. Fine basal crackles can often indicate a degree of heart failure and some fluid beginning to gather in the lungs. Coarser crackles can be cause by secretions which pop on expiration and can often indicate a chest infection.


Pleural effusion

  • reduced tactile vocalfremitus
  • reduced chest expansion
  • stony dull
  • reduced air entry
  • no added sounds
  • reduced vocal resonance

Consolidation

  • increased tactile vocal fremitus
  • reduced expansion
  • dull percussion
  • bronchial breathing
  • coarse crackles
  • increased vocal resonance

 

Pneumothorax

  • deviated trachea
  • reduced tactile vocalfremitus
  • hyper-resonance
  • reduced air entry
  • reduced vocal resonance

Collapse

  • deviated trachea
  • reduced tactile vocal fremitus
  • dull percussion
  • reduced air entry
  • +/- creps
Clinical Methods, 3rd edition
The goal of this book is to "be your guide" and say "see here and see there" as the reader becomes skilled in the techniques and analysis of clinical data. This third edition of Clinical Methods has undergone substantial revision based upon feedback from students and other users of the first two editions. These changes enhance the usefulness of the book and help us to achieve our goal of providing clinicians and students with the best current knowledge of the techniques of collecting and using clinical data

Dr Eric Strong - Heart Murmurs - (Part 3 of 3)

A lecture on the characteristics and identification of heart murmurs

Dr Eric Strong - Heart Murmurs - (Part 2 of 3)