year 1 mbchb clinical skills session respiratory examination · 2020-02-06 · following images...
TRANSCRIPT
Year 1 MBChB
Clinical Skills Session
Respiratory Examination
Written by: The Clinical Skills Lecturer Team
Reviewed & ratified by:
MBChB Lead Dr Eion Judge
January 2020
Respiratory Examination
Aims and Objectives
Aim: To be familiar with the elements of a respiratory examination.
Respiratory rate
Oxygen saturation
Percussion & auscultation of the lungs
Objective: To revise anatomy & physiology of the lungs
Objective: To understand the anatomy & physiology, applying it to
the practical skills.
Objective: To be able to percuss & auscultate the lung fields
Objective: To understand reasons for undertaking a respiratory
rate and oxygen saturation.
Objective: To be able to measure a respiratory rate and oxygen
saturation.
Theory and background
Underpinning a respiratory examination is the knowledge of anatomy &
physiology together with applying the basics of the examination,
knowing why you do and knowing how to do or obtain the following:
1. Respiratory rate
2. Oxygen saturation
3. Chest expansion
4. Palpating an apex beat
5. Percussion
6. Auscultation
Additionally a respiratory exam is usually combined with a
cardiovascular exam and called a cardiorespiratory exam.
Know your anatomy
In order, to ensure that you perform a comprehensive examination of
the chest, you need to know the surface anatomy of the lungs. The
following images demonstrate the borders of the lungs and the surface
markings of the individual lobes. However, it should be remembered
that the lungs are a moving structure and the following are the most
common approximations of the positions. This link will take you to an
anatomy video produced by Dr Alistair Bond HARC.
https://files.fm/u/guhjtmm3
Surface marking of the lungs
Anterior chest wall
Copyright © 2020 Elsevier Inc
Lateral chest wall
Copyright © 2020 Elsevier In
The inferior border of the lung
(at rest) extends down to the
6th rib
The oblique fissure is marked
anteriorly by the point at
which the midclavicular line
crosses the sixth rib
The horizontal fissure on the
right is marked by the position
of the 4th costal cartilage.
The horizontal fissure extends as far as the oblique fissure in the mid-axillary line The lower border of the lung extends to the 8th rib in the mid-axillary line
Posterior chest wall
Copyright © 2020 Elsevier Inc
Procedure
Patient safety
On first meeting a patient introduce yourself, confirm that you have the
correct patient with the name and date of birth, if available please
check this with the name band and written documentation and the
NHS/ hospital number/ first line of address.
Check the patient’s allergy status, being aware of the equipment you
will be using in your examination. Ensure the procedure is explained to
the patient in terms that they understand, gain informed consent and
ensure that you are supervised, with a chaperone available as
appropriate. Don personal protective equipment (PPE) as required,
The inferior border of
the lung is marked by
the 10th or 11th rib.
The oblique fissure
extends up to the 4th
thoracic vertebrae
especially if you are likely to come into contact with bodily fluids. For a
respiratory exam you would not normally need to wear PPEs.
As part of the consent process you will need to advise the patient that
they may need to lean forward for part of the examination.
Be aware of hand hygiene and preventing the spread of disease, WHO
(2018) http://www.who.int/infection-prevention/tools/hand-hygiene/en/
Prior to any clinical examination a detailed history should be taken
from the patient, this will enable you to tailor the examination to the
patients presenting complaint and additional symptoms the patient
may elude to when you elicit a full history. For guidance on history
taking please click MBCHB students – Year 1 – History taking.
General inspection
Look at your patient and note or measure their general demeanour,
noting any signs of breathlessness, are they sweating or showing
signs of pain or discomfort. Do they look cachexic (see glossary) and
are they a normal colour, or are they showing signs of cyanosis or
pallor.
CSTLC 2019
Have a look around the bed, are there any clues that the patient has
respiratory problems. There may be oxygen, inhalers and urine bottles
(due to reduced mobility) etc.
You will need to check their vital signs their respiratory rate and oxygen
saturations (SpO2), as well as their pulse, temperature and BP which
will be covered in other teaching sessions in year 1 and 2. Additionally
you will need to inspect the anterior, lateral and posterior aspects, so
the patient will need to lean forward (and may need assistance to do
so). It is better to inspect, palpate, percuss and auscultate all aspects
of the anterior and lateral chest, then lean the patient forward and do
the same on the posterior aspect.
Respiratory rate
The respiratory rate is measured by the number of respirations
observed occurring in 1 minute. This is the respiratory rate, (1
respiration = 1 breath IN + 1 breath OUT). It is best to do this covertly
as, if the patient is aware you are checking their respiratory rate, they
may alter their breathing (such as breathing more noticeably) to help
you.
The normal healthy adult range is 12 – 20 respirations per minute. As
well as working out the rate of the respirations, you can also describe
the depth, rhythm, if the chest is moving in symmetry and the sound of
patients breathing.
Surface percutaneous oxygen
saturation (SpO2)
SpO2, also known as ‘Sats’ is the
measurement of the amount of oxygen
in the blood. A probe measures the
haemoglobin binding sites occupied by
oxygen in the blood. The measurement
is expressed as a percentage and the normal parameters are 94 –
100% on air (i.e. the patient does not have supplementary oxygen).
The body maintains a very precise balance for organ function. The
device used to measure the SpO2 is called a Pulse Oximeter. There
are different types of probes used depending on the part of the body
they are attached to, i.e. finger or ear. There are also different probes
for adults and children. It is important to use the correct probe on the
correct part of the body or it can produce a reading 50% lower or 30%
higher than the real value.
Inspection of the chest
Having already done a general inspection you should now visually
inspect the chest, you will need to inspect the anterior, posterior and
lateral aspects of the chest. You should check for rashes, scars,
lesions, deformities, the shape of the chest, signs of trauma etc.
Observe the breathing pattern for the depth, regularity, symmetry and if
any accessory muscles are being used to aid respiration.
CSTLC 2019
Palpation
Following inspection you should palpate the chest. You would start with
a general palpation to check for signs of tenderness, trauma etc. You
should also palpate for an apex beat (see CVS examination study
guide https://liverpoolclinicalskills.com/home/mbchb-students-2/year-
1/cardiovascular-examination/cardiovascular-examination-study-guide/
Percussion
Percussion is tapping on an
area to try and determine what
is underneath. You should
ensure you cover all lung
lobes (make sure you know
the anatomy). Place your
middle finger firmly in the
intercostal spaces (lay finger
along intercostal space) and tap with the middle finger of the other
hand. When percussing the clavicles, tap your finger directly on to
bone. You should compare sides by alternating similar areas on right
and left. As with inspection you should remember to assess the
anterior, lateral and posterior chest.
CSTLC 2019
See “Basics of examination” study guide
(https://liverpoolclinicalskills.com/home/mbchb-students-2/year-
1/basics-of-examination/) for how to percussion.
Percussion notes
There will be different sounds heard on percussion. When percussing
over the clavicles (overlying lung apices) or over normal lung tissue,
there will be a resonant sound. When you percuss over the heart or
Liver you will hear a dull sound.
Auscultation
For auscultation ask the patient to breathe in deeply, in their own time,
with an open mouth, making it easier for the patient and easier to hear
the breath sounds. Using the diaphragm or the bell (may be helpful if
patient is hairy as the hair will rub on the diaphragm causing added
sounds) of the stethoscope you need to compare the right and left
sides as you move down the chest. Auscultate a large number of sites
to ensure all the lobes are examined (remembering the lung borders)
and, as always auscultate the anterior, lateral and posterior chest
walls. You should listen for breath sounds, defined as vesicular if they
are normal although you can hear bronchial sounds in health if you are
listening over the sternal edge of around the 2nd / 3rd intercostal space
on the anterior chest wall.
Vesicular breath sounds
Vesicular breeath sounds are normal finding over the peripheral lung
fields. They are quiet and low pitched with no gap between the phases
of inspiration and expiration. However the expiratory phase is shorter
than the inspiratory phase.
Most clinicians will examine all elements on the anterior chest wall
(inspection, palpation, percussion, auscultation) and then repeat the
examination for the posterior and lateral chest. This avoids the patient
moving back and forth multiple times which may be difficult, especially
if they are short of breath.
CSTLC 2019
Glossary
Cachexic – Patient looks physically unwell and as at risk of death.
Cyanosis – A bluish tinge due to poor circulation/ oxygenation
Pallor – Paleness or lack of colour
Vesicular – Normal breath sounds
References
Haynes JM. The ear as an alternative site for a pulse oximeter finger
clip sensor. Respiratory care. 2007 Jun 1; 52(6):727-9.
Mannheimer PD. The light–tissue interaction of pulse oximetry.
Anaesthesia & Analgesia. 2007 Dec 1;105(6):S10-7.
Walters TP. Pulse oximetry knowledge and its effects on clinical
practice. British journal of Nursing. 2007 Nov 22;16(21):1332-40.