Slide 1

Assessment of the Respiratory

System

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Slide 2

Physical Assessment

Objectives

Structure

Symptoms of respiratory disease

General examination

Focussed examination

Assessing respiratory function

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Slide 3

Physical Assessment

Structure

Anatomy & physiology

Surface anatomy

§ Upper lobe

§ Lower lobe

¥ Middle lobe

Lung Function

§ Oxygenate blood

§ Remove CO2

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Slide 4

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Slide 5

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Slide 6

Physical Assessment

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Slide 7

Physical Assessment

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Slide 8

Physical Assessment

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Slide 9

Physical Assessment

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Slide 10

Physical Assessment

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Slide 11

Physical Assessment

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Slide 12

Physical Assessment

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Slide 13

Physical Assessment

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Slide 14

Physical Assessment

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Slide 15

Physical Assessment

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Slide 16

Physical Assessment

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Slide 17

Physical Assessment

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Slide 18

Physical Assessment

Symptoms of respiratory disease

Dyspnoea

§ Causes

§ Duration

§ Variability

§ Asthma

§ Severity

§ Orthopnoea & PND

§ Hyperventilation

§ Hypoxia

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Slide 19

Physical Assessment

Symptoms of respiratory disease

Cough

Sputum

Haemoptysis

Pain

Wheeze & Stridor

Other body systems

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Slide 20

Physical Assessment

Overview

General Appearance

Cough & abnormal

sounds

Hands, Face & Neck

Inspect chest

Palpation

Percussion

Auscultation

Contemplation

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Slide 21

Physical Assessment

General Appearance

Bedside clues

Watch respiration

Speech

Cough &

abnormal sounds

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Slide 22

Physical Assessment

General Examination

First impressions

§ Clubbing

§ Cyanosis

¥ Central cyanosis

¥ Peripheral cyanosis

§ Tremors

§ Pulse & blood pressure

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Slide 23

Physical Assessment

Respiratory Signs

Chest movement with respiration

Rate of respiration (12-15/min)

Air entry - symmetrical? reduced?

Vocal Resonance?

Percussion note - resonant, dull

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Slide 24

Physical Assessment

Hands Face and Neck

Skin temperature

Tar staining

Cyanosis

Finger clubbing

Pulse

Tremor

Blood pressure

JVP

Nose

Eyes

Lymph nodes

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Slide 25

Physical Assessment

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Slide 26

Physical Assessment

Focussed Examination

Inspection

Palpation

Percussion

Auscultation

§ Contemplation

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Slide 27

Physical Assessment

Focussed Examination (cont)

Inspection

§ Chest wall

§ Breathing patterns

§ Pink puffers & blue bloaters

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Slide 28

Physical Assessment

Inspection of the Chest

Surface markings

Shape

Breathing pattern

Movement

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Slide 29

Physical Assessment

Focussed Examination (cont)

Palpation

§ Trachea & mediastinum

§ Chest wall

Systematic approach

§ Comparison made with both sides of body

§ Start from front – apex of lung & work down

¥ Lateral sides & axilla

§ Sit patient forward – examine back

§ Vocal fremitus

§ Chest expansion

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Slide 30

Physical Assessment

Palpation

Mediastinal position

Chest expansion

Tactile vocal fremitus

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Slide 31

Physical Assessment

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Slide 32

Physical Assessment

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Slide 33

Physical Assessment

Focussed Examination (cont)

Percussion

§ Detect resonance or hollowness of chest

§ Technique

¥ Bell clapper

¥ Compare each side

¥ Finger on chest parallel with expected line of dullness

¥ Placed over IC space

¤ Apex of lung = mid clavicle

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Slide 34

Physical Assessment

Percussion

Technique

Findings

§ Resonant

§ Dullness

§ Stoney dullness

§ Hyper-resonant

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Slide 35

Physical Assessment

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Slide 36

Physical Assessment

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Slide 37

Physical Assessment

Focussed Examination (cont)

Auscultation

§ Correct use of stethoscope

§ Technique

¥ Start at apices, work down, comparing each side

§ Report on:

¥ Breath sounds¤ Vesicular or Bronchial

¥ Added sounds¤ Crackles (crepitations/rales), wheezes (rhonchi), stridor and rubs

§ Vocal resonance

¥ Whispering pectoriloquy

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Slide 38

Physical Assessment

Auscultation

Technique

Findings

§ Vesicular

§ Reduced

§ Bronchial

¥ Added sounds

¤ Wheeze

¤ Crackles

¤ Rub

§ Vocal resonance

¥ Whispering

pectoriloquy

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Slide 39

Physical Assessment

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Slide 40

Physical Assessment

Breath Sounds

Vesicular§ Heard over normal lungs

¥ Rustling quality

¥ Heard on inspiration and first part of expiration

Bronchial§ Difficult to describe

¥ Described by its timing

Added sounds§ Crackles (rhonchi)

§ Wheezes (rales; crepitations)

§ Rubs

Vocal resonance§ 99

¥ Fuzzy sound

¥ Whispering pectoriloquy

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Slide 41

Physical Assessment

Respiratory Investigations

Sputum examination

CXR - chest radiograph

Pulmonary function

§ PEFR - maximum flow rate

§ FEV1 - forced expiratory volume

§ FEV1/VC - measure of resp. function

Bronchoscopy

VQ scan - ventilation/perfusion mismatch

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Slide 42

Physical Assessment

Lung Function Tests

PEFR

FVC

FEV1

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Slide 43

Physical Assessment

Assessing Lung Function

Static Lung volumes

§ Total Lung Capacity (TLC)

§ Vital capacity (VC)

§ Tidal Volume (TV)

§ Residual Volume & Forced Residual Volume

Dynamic lung volumes

§ Spirometry

§ VC; FEV1;FEV1%

Peak flow

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Slide 44

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Slide 45

Physical Assessment

Peak Expiratory Flow Rate

Flow generated by first 0.1s of a forced

expiration

§ Figure is extrapolated over 1 min

§ Normal ratio dependant on age & sex

Serial recording useful in diagnosis &

management of asthma

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Slide 46

Physical Assessment

Forced Vital Capacity

Measured by spirometric trace

§ Forced exhalation from total lung capacity (TLC) to

residual volume (RV)

§ Amount exhaled forcefully from a single deep

inspiration

FEV1 is fraction of that volume in first one

second

§ Expressed as ratio FEV1/FVC (FEV1%)

¥ Normally 75%

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Slide 47

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Slide 48

Physical Assessment

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Slide 49

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Slide 50

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Slide 51

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Slide 52

Physical Assessment

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Slide 53

Physical Assessment

Severity

COPD diagnosed if:

§ FEV1 <80% predicted

§ FEV1/FVC <70%

Severity is measured

using FEV1:

§ <80% = mild

§ <60% = moderate

§ <40% = severe

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Slide 54

Physical Assessment

Framework for respiratory

examinationWhilst taking history note any respiratory distress

Look at hands for clubbing, cyanosis

Mucous membrane for central cyanosis

Check JVP

Inspect chest wall

§ Deformities and inequalities

Pattern of breathing

Palpate trachea for displacement

Assess expansion of chest from front

Palpate for vocal fremitus

Percuss front of chest

Auscultate chest and decide on nature and presence of breath sounds

Test for vocal resonance and ‘whispering pectoriloquy’

Note added sounds

Repeat for back

PFR

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