42 SYSTEMS - RESPIRATORY

RESPIRATORY EXAMINATION (I)

INTRODUCTION It is often easier to examine the chest with the patient standing if possible. Celtainly percussion and assessment of respiratory movements of the lung bases at the back is difficult if the patient is sitting in bed. The possible signs of acute respiratory disease are shown in Figure I and chronic respiratory disease in Figure 2 . Before utilizing the conventional se­quence of inspection, palpation, percus­sion and auscultation, three observations should be made.

Observe the breathing pattern Prolonged expiration occurs in bronchial narrowing or in inflammation of the bronchi and smaller airways (as in bron­chitis). Restrictive lung disease, as may be found in diffuse fibrosing processes, may be suspected (but not actually diag­nosed) if the diminuendo of expiratory wheeze ceases abruptly (as the restricted lungs suddenly reach the end of their elastic recoil potential). In contrast, the wheeze of bronchial narrowing often progressively diminuendoes away to nothing without a cutoff point.

Stridor is a wheezing noise generated at the larynx or above. Unlike lower respiratory tract wheezing, the wheezing of stridor is audible well away from the patient and is of approximately equal intensity and duration in both inspiration and expiration.

Examine the sputum pot Yellow or green sputum usually signifies infection (numerous eosinophils in aller­gic lung disease can also discolour the sputum). Copious amounts of sputum suggest bronchiectasi s or lung cavities that are draining into the air passages. Mucoid (watery) sputum may be found in severe pulmonary oedema, asthma, or in uncomplicated viral pneumonias. Foul-smelling sputum suggests infection with anaerobic bactelia.

Voluntary cough Ask the patient to cough and note the characteristics as outlined previously (p.36).

INSPECTION Observe the pattern of shortness of breath and the respiratory rate. Observe the patient's colour.

• Confusion, drowsiness , ~ coma Herpes labial IS

• Raised jugular venous J::::'-'~ pressure caused by right \ ' ventricular failure (cor / • Cough pulmonale) ( • CyanosIs

• Papilloedema or distended ,. • Breathing with pursed lips fundal veins in respiratory \ • BreathlessnesskI

failure : . Intercostal indrawing • Rapid bounding pulse • Use of accessory muscles

with carbon dioxide of respiration and indrawing I \\ retention I \ of supraclavicular fossa

• Asymmetry of chest signs • Abnormal duration of

inspiration or expiration • Abdominal respiratory

pattern (minimal chest movement)

• Crackles or wheezes • Cheyne-Stokes

respiratory pattern possible

Fig. 1 The possible clinical findings in acute respiratory disease.

• Papilloedema or distended • Plethora fundal veins in respiratory " • Cyanosis failure

Barrel-shaped chest .-,---1-\-- • Tricuspid incompetence

• Palapable right ventricle

• Reduced cardiac dullness • Loud pulmonary second in emphysema sound reflecting

pulmonary hypertension • Crackles or wheezes • Abdominal respiratory

pattern (minimal chest movement)

• Subcostal angle greater than 90 degrees

• Cheyne-Stokes respiration ­a cyclical waxing and waning Clubbing in chronic of respiratory depth over suppurative lung disease about one minute or primary neoplasia

Fig. 2 The possible findings of chronic respiratory disease. Signs of acute disease may be superimposed.

Cyanosis about 5 g or more of desaturated haemo­Cyanosis is a bluish discoloration which globin: thus patients with a severe may be central or peripheral in distli­ anaemia of less than 5 g cannot become bution. Central cyanosis is best identified cyanosed. Patients with polycythaemia by observing the tongue which, being (who have excessive haemoglobin) are central and warm, cannot develop a often cyanosed. Some patients fight cyanosis of pelipheral causation . cyanosis by hyperventilation ('pink

Cyanosis may occur if the oxygen puffers') whereas others surrender and saturation of blood leaving the lungs is become 'blue bloaters' (Fig. 3). about 75% or less. Cyanosis requires In contrast, pelipheral cyanosis (in the

Fig. 3 A typical 'blue bloater'.

absence of central cyanosis) signifies an impaired peripheral circulation such that the haemoglobin in the sluggishly circulating red blood cells becomes significantly more deoxygenated than normal, thus causing cyanosis. The causes of peripheral cyanosis are thus those of an impaired circulation rather than respiratory disease.

Causes of central cyanosis (caused by desaturated biood being distributed by the arterial system) include asphyxia, hypoventilation , impaired oxygen trans­fer across the lungs or venous to arterial shunting of blood. Chronic central cyanosis caused by respiratory disease is most often caused by chronic obstructive air­ways disease or fibrosing alveolitis. Because cyanosis induces vasodilation, the peripheries are often blue, warm, and with full bounding pulses.

The depth, frequency and character of breathing The depth , frequency (normally between 15 and 20 per minute) and character of breathing should be noted . Note whether the patient uses unusual accessory muscles of respiration (e.g. the sternomastoids) to attempt adequate ventilation of the lungs, or whether there is an abnormally expanded chest wall such that abdominal muscles have to be used for respiration. Note also whether there are scars from previous chest surgery and if the chest wall is asymmetric or flattened. Obvious skeletal deformities of the spine include a kyphosis (an excessively curved thoracic spine in the anterior posterior dimension) and scoliosis (a laterally curved spine), either of which may interfere with chest ventilation. Assess whether respiratory excursion is limited, although in the absence of previous measurements this must be rather subjective.

If there is chest asymmetry or reduced movement on one side then the side of

pathology is almost invariably the side of reduced movement. Never say that there is increased movement on one side of the chest but rather say that there is reduced movement of the other side.

Suspect chronic obstructive airways disease if the chest is barrel shaped. This appearance is caused by an increase in the anteroposterior diameter of the chest, horizontal ribs and clavicles, and a subcostal angle greater than 90° because the chest wall muscles have been attempting to ensure maximum ventilation by maximum elevation of the ribs.

Other signs Other signs which may be seen include clubbing (p. 8) or enlarged lymph nodes and Horner's syndrome (a unilateral pto­sis, a small pupil, a slightly sunken eye­ball and loss of sweating; p. 99). Horner's syndrome may be a sign that malignant tiss ue has invaded and inter­rupted the sympathetic nerve supply to the eye.

In hospital practice the nursing ob­servation chart should be noted. If the patient is febrile from any cause, the respiratory rate is usually increased by about five for each degree centigrade rise in temperature, but if respiratory infection is the cause the respiratory rate rise is often greater than this.

PALPATION Position of the mediastinum The position of the mediastinum should be determined by ascertaining that the trachea and the apex beat are in their normal position (very slightly to the right of the midline and the fifth intercostal space in the midclavicular line respec­tively). Palpation of the trachea is best performed (with the patient's neck in the normal upright position) by placing the index finger in the suprasternal notch and ascertaining that it is slightly easier to push to the left of the trachea than to the right (Fig. 4). If there is airways ob­truction, the trachea is moved ('tugged') downwards on inspiration. This can be best appreciated by feeling movements of the thyroid cartilege. Displacement of the mediastinum occurs when it is pushed from one side (by a pneumotho­rax, a large accumulation of pleural fluid or by other space-occupying lesions), or pulled to the other side (by pulmonary collapse or fibrosis).

Respiratory excursion Respiratory excursion of all areas of the chest should be assessed, comparing the right side with the left side. To

4

Fig. 4 Palpation to ascertain the position of the trachea.

determine whether there is asymmetry of chest movement, place your relaxed hands symmetrically on either side of the patient'S chest with your fingers over the two areas to be compared. Then concentrate on feeling chest movements. Simultaneous inspection often detracts from this assessment.

Assessing the voice Tactile vocal fremitus is appreciation of voice sounds by a palpating hand: vocal resonance, which uses the stethoscope to pick up the same voice sounds, yields the same results. Most physicians rarely use tactile vocal fremitus, preferring the more easily assessable vocal resonance.

Other signs Air may enter the subcutaneous tissue (usually with a tension pneumothorax or in association with therapeutic chest needling) causing swelling and a curious crackling sensation on palpation of the skin.

Respiratory examination (I)

• A full sputum pot suggests bronchiectasis.

• An empty sputum pot in a patient with chronic respiratory symptoms suggests a non-respiratory aetiology, an interstitial pulmonary process or asthma.

• Chronic chest conditions may cause secondary right ventricular failUre- cor pulmonale.

• Crackles or wheezes may occur in patients with a normal chest X-ray: believe your stethoscope.

RESPIRATORY EXAMINATION (I)