Respiratory Exam

Original article by Tom Leach | Last updated on 17/10/2014
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For a quick overview of the respiratory system exam, please see the Introduction to Respiratory Exam article

 

General Instructions

  • Always examine the patient from their right.
  • Make sure you get consent at the start of the examination, but then you don’t need to keep asking the patient again as you do the rest of the examination! You should still explain what you are going to do, but don’t keep asking them if its ok.
  • Remember you are always comparing the two lungs. Practice lots so you know what normal is.
  • You may also be asked to palpate the apex beat to see if it has been displaced.
  • Always ask the patient to strip to the waist, even women! Check they feel comfortable, women may want to keep a bra on, and always explain what you are doing, so that they don’t think you are just having a grope!
  • The middle lobe of the lung can only be auscultated from the axilla and back of the patient.
  • About 90% of diagnostic information will be gained from patient history – therefore examination should only ever be used as a subsidiary! Never just dive in and examine someone without knowing the proper history first.
  • Always look for a sputum pot!
    • Yellow/green sputum – sign of infection
    • Massive amounts of sputum – most likely bronchiectasis
    • Look for signs of blood – could be infection, could be malignancy
    • You may get very suspicious if they also have a hoarse voice and/or weight loss
 

Chest Examination

General observation of the patient

Introduce yourself, and say what you are going to do. Don’t just say you are going to examine the chest, because you are also going to examine other body parts! Wash your hands. Don’t be worried about asking the patient to strip. It’s ok to tell a female patient she can cover up if she wants to. If you are nervous about asking the patient to take off their clothes this can lead to a confidence issue and mean the rest of the examination does not flow smoothly.  If you are examining a woman, then you should always make sure a chaperone (a female nurse or medical student) should ALWAYS be present.
 

Inspection

  • check the colour of the patient (e.g. are they cyanosed)
  • patient should be sat at 45’ for this examination. If the patient is very breathless in this position, then allow them to sit up straight. Patient comfort is the most important factor.
  • see if there are any obvious signs of weight loss
  • see if there is any ‘’breathlessness’’ – see if they are already propped up on many cushions (heart failure)
  • see if there is any wasting of the accessory muscle of breathing. This may be present if the patient suffers from COPD)
  • see if the patient is pursing their lips on breathing.
  • look at the patient’s expiratory time. Normally expiratory time is shorter than inspiratory time, however, in lung diseases, often there is very short inspiration followed by prolonged expiration.
  • listen if there are any audible breathing sounds (normally there aren’t.)
  • check the surroundings, e.g. is there oxygen, inhalers or a nebulizer etc. as these are clues to possible respiratory disorders. Also look for a drip, any medications, sputum pots, nasal specs or masks.
 

Patient’s Hands

Check for signs of clubbing. The four features of clubbing are:
  1. Loss of the angle of the nail bed
  2. Drumstick-like appearance
  3. Boggy nailbed (increased fluctuance)
  4. Increased curvature of the nail
  • Respiratory causes of clubbing include: Empyema, Bronchiectesis, Non-small cell carcinoma, Lung fibrosis, CF, Abscesses, suppurative diseases – diseases that produce a lots of pus!
  • Check for signs of cyanosis
  • check for tar staining
  • Duypetren’s contracture
  • check for asterixis. Ask the patient to hold out their arms and bend their wrists so that their palms are vertical pointing away from them. Wait up to 30 seconds. If there is a flapping tremor (a ‘coarse flap’) this suggests a retention of carbon dioxide.
  • Other signs that show CO2 retention include warm sweaty palms (due to vasodilation), and a bounding pulse – always check the pulse!
  • Koilonychia – iron deficiency anaemia.
  • Leukonychia – white nailsa as a result of hypoalbuminaemia – liver disease
  • Beau’s lines – sign of serious illness in the past 3 months (nails take 3 months to grow fully). They are horizontal ridges in the nail – a bit like rings in a tree trunk.
  • Splinter haemorrhages (endocarditis) – although they are very commonly caused by trauma (manual labour).
  • Fine tremor – there is a fine tremor often present in respiratory patients that is caused by β2- agonists – i.e. salbutamol.
  • Check the BP – or at least say you would check it
 

Check the pulse!

  • Rate – tachy >100 / norm / brady <60
  • Rhythm – regular / irregular / regularly irregular / irregularlyirregular
  • Character
    • Bounding pulse – anything with hyperdynamic circulation – fluid overload e.g. aortic regurg, thyrotoxicosis
    • Slow rising pulse – put four fingers on the pulse (radial or carotid) and you can feel the pulse hit each of your fingers in turn caused by aortic stenosis. in the normal individual it should hit all fingers at once.
 

Patients head / neck

  • check for cyanosis on the underside of the patient’s tongue.
  • check for lesions
  • check the eyes - e.g. for anaemia, jaundice, xanthelasma and Horner’s sign – consists of: constricted pupils, a droopy eyelid and reduced sweating – all on the same side of the face – e.g. no sweating on the affected side of the face. This is a common symptom of an upper lung tumour.
    • Sympathetic nerves cause dilation of the pupil
    • Parasympathetic cause constriction. Thus in this case, there is no sympathetic, so the pupil is always constricted – however – as the parasympathetic is still active, you may be able to constrict the pupil even further by shining a light into it – this does not mean that Horner’s is not present!
    • The arrangement of sympathetic nerves in this area – the sympathetic chain! – 1st order neurons travel from the brain, to the spinal chord between levels C8 and T2. From here, second order neurons pass out of the spinal chord, out over the apex of the lung, and then up alongside the carotid artery, to the superior cervical ganglion. There are then two sets of nerves originating from here. One lot of these 3rd order neurons goes over the cavernous sinus and to the eye, the other goes along the external carotid and then goes to the sweat glands of the face.
    • A lung tumour can damage the second order neurons over the apex of the lung, resulting in Horner's Sign
  • Arcus – caused very commonly by age, and the least common cause is Wilson’s disease.
  • check for angular stomatitis – sign of iron deficiency anaemia and pernicious anaemia
  • Check for glossitis – can be a sign of iron deficiency anaemia or pernicious anaemia (b12 deficiency)
  • Check under the toungue for central cyanosis
  • Smell the breath – check for ketones – smell like pear drops
  • Check dental state
  • Look for thrush and leukoplakia – signs of immunosupression – thus can be linked with chest infections
  • HHT – hereditary haemorrhagic telangactasia
  • Purtz-Jager-syndrome (PJS) – freckles on the lips.
  • Buccal pigmentation – caused y Addisson’s disease – a brown discolouration.
  • Ocronosis – grey pigmentation of the skin around the oropharynx – and theu urine will also turn dark on standing.
  • Check for general signs of swelling – this can be caused by SVC obstruction as a result of lung cancer. The cancer can either cause this directly, or can cause a thrombus in this region. The SVC collects blood from the head, neck and arms. When this is blocked there is swelling in the head and neck and engorged veins. There is a loss of the normal JVP pulsations – because the JVP becomes raised and non-pulsatile. The head and neck becomes swollen, but there is enough collateral circulation to spare the arms. There may be visible distended veins on the chest wall.
 
 

Neck

Feel for signs of inflamed lymph nodes with your hands: start with submandibular and submental lymph nodes, then move backwards and check the lymph nodes running anterior to the SCM muscle, then run along towards the clavicle, then up the back of the neck, then check all the way up to the occipital nodes. If occipital lobes or inflamed this is possibly a sign of knit infestation! Don’t forget to check the lymph nodes of the axilla! You should check in the apex of the axilla, and also the lateral aspect. This can be quite a tricky area to feel so you should get the patient to relax by asking them to go floppy before you try to feel this area.
 
 

JVP

You probably won’t have to check this in a respiratory exam but you should say that you would if you had time. The JVP is a measure of the pressure in the internal jugular vein. This vein connects directly to the right atrium without any valves and thus is a reasonable measure of central venous pressure.
 
The patient should be at laid at 45’
 
Ask the patient to turn their head towards you, keeping their shoulders at 90’ to you. The vein runs between the two heads of SCM and up the side of the neck, to behind the ear.
  
In a normal patient, the JVP is not always visible. However, It is often raised in cor pulmonale. In a healthy patient, you may make it more visible by pressing on the liver – this forces blood into this vein, because there are no venous valves between this vein and the liver.
 
You can also check the JVP by pressing on the neck to occlude the internal jugular vein. If you do this you may start to see venous blood piling up behind your blockage. When you remove your finger, in a normal patient, the column of blood you were holding up will drop straight down, but if there is some problem with venous pressure e.g. cor pulmonale, then the column of venous blood may not instantly drop downwards. 
 
If you can’t see it, then normally this means it isn’t raised,
 
 

Trachea

Tell the patient it may feel uncomfortable. Put your second and fourth fingers on the two heads of the clavicles, leaving your middle finger free to feel the trachea.. You should be able to feel the tracheal rings, and also check the trachea has not been displaced. Reasons for displacement:
Tension pneumothoraxthis will shift the trachea away from the side of the pneumothorax.
Collapsed lobe of lung – this will shift the trachea towards the side of the collapse.
 

Lymph nodes

In a really thorough chest exam, ideally, you should examine the lymph nodes.
  • lung cancer can spread to the lymph nodes of the neck
  • when it does, it usually produces very hard nodes, that form a mass, which is fixed to underlying structures
  • nodes associated with lung cancer are most commonly found in the supraclavicular area, particularly between the clavicular heads of SCM.
  • Other causes of lymph nodes enlargement tend to cause rubbery (not hard) nodes, and these are not usually tethered to underlying structures.
 

Causes of enlarged lymph nodes

Malignancy
Lymphoma, chronic lymphatic leukaemia, local metastatic cancer spread
Viral
Infectious mononucelitis, CMV, HIV, local viral infection
Bacterial
TB, syphilis, brucellosis, local bacterial infection
-
-
For examination of lymph nodes, please see neck exam
 
 

CHEST

Inspection – Palpation – Percussion – Auscultation
 

Inspection

A normal respiratory rate is 12/13 per minute. If the patient is nervous, this could easily rise to 16. You should try and asses this without the patient knowing you are doing so.
You should check the shape, size and movement of the chest, just by looking at how it moves up and down.
Look for scars
 

Palpation

First of all, you should asses the upper part of the chest. Ask the patient to take a deep breath out, then, lay your hands on flat on the upper part of the chest, and ask them to take deep breaths. Yu should feel both sides of the chest moving in and out equally. Remember the ribs of the chest move like bucket handles.
For the lower part of the chest you should use fingertips and the lateral aspect of the chest, and put your thumbs next to eachother in the middle of the chest. Really ‘scoop’ up the chest in your hands. It is easier to feel expansion here than in the upper part and you should see your thumbs move away from eachother as the patient breathes in. You should check that both hands deviate equally.
check both the front and back! – i.e. check for expansion twice; once on the front and once on the back.
when checking on the patient’s front, your hands should go under the patient’s breasts
You should also feel for vocal fremitus. Here you ask the patient to say ‘99’ and feel their chest for resonance. You should use the side of your hand (i.e. down the edge of your little finger) and make ‘v’ shapes on the patient’s chest with your palms facing upwards as you feel both sides of the chest at the same time. It is actually much easier to hear* differences in fremitus that is to feel them. If you ask the patient to whisper ‘one, one, one, one’ and use your stethoscope then you can hear fremitus. If there is consolidation then on the side that there is consolidation you will here ‘one’ very clearly through your stethoscope.
In consolidation, there is a loud-speaker effect of fremitus! – i.e. fremitis is better on the side of consolidation!
Make sure you feel on both the front and the back, and at all the places

  • Front – apices, upper lobs, laterally
  • Back – upper lobes, lower lobes
 

When you hear it, it is called whispering pectoriliquae. it is easiest to hear when they whisper (rather than talking).
You can listen for it while they are talking, in which case it is called vocal resonance. You just get them to say ‘99’ in the same way you would when feeling for it. Make sure you listen over:

  • The apices
  • Upper lobes
  • Lateral aspects (under axilla)
  • Upper and lower lobes on the back
  • These are all basically the same places you would listen for the breath sounds!

Increased vocal fremitus – consolidation
Decreased vocal fremitus – empyema, pneumothorax,pleural effusion
Sound waves travel more freely through solid (i.e. consolidation) than through air. Liquid, or air, or anything that increases the distance between the lung and the chest wall will cause decreased fremitus.
Assessing vocal fremitus is most useful when combined with percussion:

 
Condition
Percussion
TVF (tactile vocal fremitus)
Normal chest
Same on both sounds, normal resonance
Same on both sides, can feel some fremitus
Stony dull (on affected side)
Decreased on affected side
Collapse
Dull (on affected side)
Decreased on affected side
Consolidation
Dull (on affected side)
Increased on affected side
Hyperresonant (on affected side)
Decreased on affected side
…as you can see, no combination is the same!
 

The book also suggests you may want to palpate the precordium and axillary lymph nodes
Precordium
Not always that useful in respiratory exam, but you may be able to palpate:
Rib fracturesthis may be highlighted by a very tender area on the chest, and a grinding/crunching sensation called crepitus. Often due to trauma, and may co-exists with pneumothorax / haemothorax. Very rarely you may find a pathological fracture from cancer.
Subcutaneous emphysema – this can cause general swelling of the head and neck, and when palpated, will produce a crackling sensation under the hand.
Apex beat – right lower lobe / right lung collapse can shift the apex beat to the right. Left lower lobe / left lung collapse can displace the beat to the left.
A tension pneumothorax or a large pleural effusion can push the beat away from the side of the pathology.
Axillary lymph nodes – these drain the breasts and the pleurae. The lungs are primarily drained through the lymph nodes of the neck. It is often possible to palpate axillary lymph nodes, although they are unlikely to be pathological if less than 0.5cm. if they are greater in size than 1cm in diameter then they are always pathological.                

  • If the lump is hard, then this is suspiscious of breast cancer or rarely, mesothelioma.
  • if the lump is firm as opposed to hard, then many generalised lymph node pathologies could apply
 

How to examine

Ask if there are any painful or tender areas. If there are, ask if you can palpate them, and do this gently. Can you elicit tenderness? Does it feel like rib injury?
Palpate any swollen areas that are suggestive of subcutaneous emphysema. Feel for the distinctive crackling
Palpate the apex beat
Examine the axillary lymph nodes. Take the weight of the patients arm on your own shoulder. Make sure you palpate the medial, anterior, lateral and posterior aspects of the axilla. If you feel any lumps, make sure you get a clear feel of size and consistency.

  • Do the same at both sides!
  • Press on reasonably hard – don’t just wiggle your fingers around, because you will just tickle them! 
 

Percussion

Lay your middle finger flat on the area you want to auscultate. Tap hard on the final joint. If it doesn’t hurt then you’re not doing it hard enough! You should do it 3 times on the front down each side of the chest, as well as under the axilla (middle lobe) and above the clavicle. Always compare left and right (i.e. do the top at the right, then the top at the left, the middle right etc etc.) If possible you should place your finger between ribs.
 

Auscultation

Normal breath sounds are called vesicular. The types of abnormal breath sounds are:
  • Wheeze – whistley, noisy breathing
  • Crackles – e.g. like a rustling crisp packet
  • Rubs – squelching squeaky sound, like walking in fresh snow
  • Crepitations – shorter that cracks.
 
Listen three times on the patient’s front and 3 times on the back. Make sure you listen under the axilla to hear the lung bases.
 

The quality of breath sounds

Vesicular – these are normal breath sounds. They are soft sounding – they sound like rustling leaves. They are caused mainly by the sound of air in the alveoli. This means the intensity of the sound gradually increases as inspiration continues, as more and more air reaches the alveoli. During expiration, vesicular breath sounds fade away, as the alveoli empty, and air is only travelling through the bronchi (which are further away from the stethoscope, and thus harder to hear).
Bronchial breath sounds – these are abnormal breath sounds.

 
There are two types of abnormality in the breath sounds:
-          Abnormal breath sounds
  • An example of this is bronchial breathing. Consolidation, fibrosis or collapse can alter the structure of the alveoli. In these instances, the breath sounds are no longer soft and rustling. Instead they become harsh. They can also be heard at different times of the respiratory cycle. They change so that they can be heard throughout inspiration, just stopping near the end (when air is only rushing through the alveoli). There is then a short gap, before air can once again be heard rushing through the bronchi. The sound is harsh, and generally louder than that of vesicular breathing.
  • Expiratory sounds tend to be louder and longer than inspiratory sounds – this is the opposite to vesicular breath sounds.
  • Detecting areas of bronchial breathing is very difficult
  • In COPD and asthma there may be quieter normal breath sounds.
  • Mild damage to the alveoli (as in mild fibrosis, consolidation or collapse) can also cause quieter breath sounds
  • Pneumothorax and pleural effusion can also cause quiet breath sounds, because they push the lungs further away from the chest wall.
  • Occasionally in very thin patients, the vesicular breath sounds are louder than in normal patients
  • Over the upper chest it can be particularly difficult to distinguish vesicular from bronchial breath sounds. In fact, in these areas, normal breath sounds that you can hear may infact be bronchial. In these instances, the normal breath sounds are referred to as bronchovesicular.
  • Rhonchi – these are long continuous sounds, that sound a bit like snoring. They are caused by obstruction to the airway; often by excess secretion of mucus, mucosal swelling or tumour tissue in the airway. They can be diffuse or localised. They are a common expiratory diffuse finding in COPD, and also found during inspiration in asthma.
-         
Added breath soundsthis is wheeze, crackles, or friction rub.
Crackles – these occur mainly in left ventricular failure (where the sound is caused by air bubbling through fluid) and in lung fibrosis (where the sound is caused by the ‘popping open’ of the alveoli. In both instances the sounds can be likened to Velcro.
  • They are nearly always inspiratory
  • They may also occur in COPD, bronchiectasis and resolving pneumonia
  • Crackles can be described as fine, medium or coarse. Fine crackles are high pitched and squeaky, course are low pitched, and medium are somewhere inbetween.

Wheeze – this is sometimes called ronchi. It is a continuous whistling sound caused by the narrowing of airways. They are usually due to small airways obstruction, such as in COPD and asthma. Wheeze is only usually heard on expiration. This may mean it is heard on inspiration and expiration, but if it is heard only on inspiration, then it is called stridor – and stridor is a very bad prognostic sign (cancer), as is monophonic wheeze (as this is caused by a single blockage to a single airway).

  • The pitch and duration of the wheeze is related to the severity of the pathology. The loudness of the wheeze is not related to the severity of the underlying pathology.
  • Rarely, heart failure can cause bronchospasm which results in a wheeze.

Friction rub – this is the sound of the two layers of pleura rubbing together as the lungs expand and contract. The main causes are pneumonia, pulmonary infarct and malignancy. Usually these causes lead to inflammation, and it is the inflammation that causes the actual rub.

  • Rub is often very localised
  • Often the patient complains of pain in the region of the sound – in which case the patient has pleurisy.
  • In contrast to crackles, rub only tends to be heard in expiration.
 
Vesicular and bronchial breath sounds
 
Vesicular
Bronchial
Quality
Quiet; rustling
Harsh, blowing
Inspiratory sound; origin
Alveoli
Bronchi
Expiratory sound; origin
Alveoli
Bronchi
Louder component
Inspiratory
Expiratory
Longer component
Inspiratory
Expiratory (e.g. COPD)
Gap
Between expiration and inspiration
Between inspiration and expiration
 
All these tests should then be performed on the patient’s back. If the patient has difficulty sitting up you can get them to turn away from you and dangle their legs over the side of the bed. Don’t keep getting them to sit up and lay back – do all the tests on their back at once. There are a few things that are different on the back. In the instance (e.g. auscultation and vocal fremitus) where you did things three times on the patients front, then you should do them four times on the patient’s back allowing for the lower lobe of the lung extending further downwards at the back.
 
FUNCTION TESTS
You may want to also do function tests n the patient if you suspect anything is wrong. These will include FEV1 (using spirometry) and PEFR.
 

Definitions

Nebulizer

This is a machine used to administer drugs to patients in the form of an inhaled mist. They are often used in severe cases of respiratory disease, and asthma, but only used in cases where a metered dose inhaler cannot be used. Usually the nebuliser accepts a liquid solution which is then vaporised by the device. The most commonly used substance is salbutamol. Corticosteroids are also commonly used.
 
The use of oral corticosteroids can lead to a yeast infection of the mouth (thrush) and can also cause hoarseness of the voice.
 

Clubbing

This is a painless enlargement of connective tissue at the distal end of the fingers. It is often symmetrical and affects the fingers more than the toes.
Clubbing is associated with many diseases; most of them are respiratory in origin.
It is also congenital – so the first question to ask when you notice this is ‘have you always had fingers like this.
 It is not associated with asthma or COPD. Clubbing is present in:
75% of patients with idiopathic pulmonary fibrosis
30% of patients with bronchiectasis*
25% of patients with lung cancer
95% of patients with congenital cyanotic heart disease (but this condition is very rare!)
The cause of clubbing is still debated. It is thought that megakaryocytes (the precursors of platelets) are to blame. They usually reside in capillaries of pulmonary tissue until they mature. However, in diseases where this tissue is damaged, they are released into the system circulation. They will then become trapped in the capillaries of the finger and release growth factors, causing the connective tissue in this region to grow.
 

Causes of clubbing

 
Normal
Rare
Respiratory
Supurative diseases – CF, empyema, bronchiectasis, non-small cell carcinoma, CFA – cryptogenic fibrosing alveolitis
Lung abcess, mesothelioma, empyema, asbestosis
Cardiac
atrial myxoma (non-cancerous tumour)
Congential cyanotic heart disease - heart disease with right-to-left shunt, infective endocarditis
Gastrointestinal
IBD (Crohn’s and UC), coeliac’s disease,
Others
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REMEMBER – loss of angle of the nailbed is the first sign of clubbing – so this is why you do the looking for the diamond thing.
 

Chest deformities

  • Pectus excavatum – funnel chest – a depress sternum - often congenital, but can also be linked to congential diseases, such as marfan’s syndrome. It is generally just cosmetic, but can have a minor effect on lung function. very rarely it can cause breathlessness.
  • Pectus carinatum – pigeon chest – a prominent sternum – often develops during childhood in patients with Rickets or severe chest disease. It is thought that it may be due to strong contractions of the diaphragm while the ribcage is still pliable. Just cosmetic, very little effect on lung function (although there may be underlying disease remember)
  • Kyphscoliosis – this is spinal deformity, resulting in increased A-P and lateral curvature of the spine. It affects 1 in 1000, and 1 in 10 000 severely. The patient will look like they have abnormal posture.It is mostly idiopathic, and first noticed in childhood. It can be quite severe (as well as being cosmetic) and often causes breathlessness in middle age.
  • Thoracoplasty – This was a surgical treatment used in the past to treat TB. It involved removal of several ribs, and thus the affected side can appear very deformed. It reduced lung capacity, which can cause breathlessness in old age (particularly in smokers).