Respiratory examination
Encyclopedia
In medicine
, the respiratory examination is performed as part of a physical examination
, or when a patient presents with a respiratory problem (dyspnea
(shortness of breath), cough
, chest pain
) or a history that suggests a pathology
of the lung
s. It is very rarely performed in its entirety or in isolation, most commonly it's merged with the cardiac examination.
e are not in the way of examining the upper lung fields.
as many physicians around world request
Lighting - adjusted so that it is ideal.
Draping - the chest should be fully exposed. Exposure time should be minimized.
The basic steps of the examination can be remembered with the mnemonic PIPPA:
Inspection of the fingers for cyanosis
or clubbing is sometimes included in the respiratory examination.
. Another type of breathing is Cheyne-Stokes respiration
, which is alternating breathing in high frequency and low frequency from brain stem injury. It can be seen in newborn babies which is sometimes physiological (normal). Also observe for retractions seen in asthmatics. Retractions can be supra-sternal, where the accessory muscles of respirations of the neck are contracting to aid inspiration. Retractions can also be intercostal, there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. This is a sign of repiratory distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for shifted trachea or one sided chest expansion, which can hint pneumothorax.
If there is pneumonia, palpation may reveal increased vibration and dullness on percussion. If there is pleural effusion, palpation should reveal decreased vibration and there will be 'stony dullness' on percussion.
Middle finger strikes the middle phalanx of the other middle finger. The sides of the chest are compared.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, the respiratory examination is performed as part of a physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
, or when a patient presents with a respiratory problem (dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
(shortness of breath), cough
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...
, chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...
) or a history that suggests a pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
of the lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
s. It is very rarely performed in its entirety or in isolation, most commonly it's merged with the cardiac examination.
Position/Lighting/Draping
Position - patient should sit upright on the examination table. The patient's hands should remain at their sides. When the back is examined the patient is usually asked to move their arms forward (hug themself position) so that the scapulaScapula
In anatomy, the scapula , omo, or shoulder blade, is the bone that connects the humerus with the clavicle ....
e are not in the way of examining the upper lung fields.
as many physicians around world request
Lighting - adjusted so that it is ideal.
Draping - the chest should be fully exposed. Exposure time should be minimized.
The basic steps of the examination can be remembered with the mnemonic PIPPA:
- Position
- Inspection (for example, "normal effort")
- Palpation (for example, "no tenderness to palpation", "fremitusFremitusFremitus is a palpable vibration on the human body. In common medical usage, it usually refers to vocal fremitus, although there are several other types.-Pleural fremitus:...
WNL") - Percussion (for example, "clear to percussion bilaterally" or "CTP B")
- Auscultation (for example, "clear to auscultation bilaterally" or "CTA B"; "no R/R/W" or "no rhonchiRhonchiRhonchi is the coarse rattling sound somewhat like snoring, usually caused by secretion in bronchial airways. Rhonchi is the plural form of the singular word rhonchus.-Description:...
, ralesRalesCrackles, crepitations, or rales are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are often heard only with a stethoscope...
or wheezes")
Inspection of the fingers for cyanosis
Cyanosis
Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
or clubbing is sometimes included in the respiratory examination.
Inspection
Inspection or observation involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. It is best to count the respiratory rate under pretext of some other exam, so that patient does not sub consciously increase his baseline respiratory rate. An acidotic patient will have more rapid breathing to compensate known as Kussmaul breathingKussmaul breathing
Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis but also renal failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or...
. Another type of breathing is Cheyne-Stokes respiration
Cheyne-Stokes respiration
Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2...
, which is alternating breathing in high frequency and low frequency from brain stem injury. It can be seen in newborn babies which is sometimes physiological (normal). Also observe for retractions seen in asthmatics. Retractions can be supra-sternal, where the accessory muscles of respirations of the neck are contracting to aid inspiration. Retractions can also be intercostal, there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. This is a sign of repiratory distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for shifted trachea or one sided chest expansion, which can hint pneumothorax.
- TrachealVertebrate tracheaIn tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
deviation (can suggest of tension pneumothorax)
Chest wall deformities
- KyphosisKyphosisKyphosis , also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae...
- curvature of the spine - anterior-posterior - ScoliosisScoliosisScoliosis is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C" than a straight line...
- curvature of the spine - lateral - Barrel chestBarrel chestBarrel chest generally refers to a broad, deep chest found on a man. A man described as barrel chested will usually have a naturally large ribcage, very round torso, large lung capacity, and will potentially have lots of upper body strength...
- chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPDChronic obstructive pulmonary diseaseChronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases... - Pectus excavatumPectus excavatumPectus excavatum is the most common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest...
- sternum sunken into the chest - Pectus carinatumPectus carinatumPectus carinatum, , also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum.-Causes:...
- sternum protruding from the chest
Signs of respiratory distress
- CyanosisCyanosisCyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
- person turns blue - Pursed-lip breathing - seen in COPD (used to increase end expiratory pressure)
- Accessory muscle use (scalene muscles)
- Diaphragmatic paradox - the diaphragm moves opposite of the normal direction on inspiration; suspect flail segment in trauma
- Intercostal indrawing
- movement of chest-chest movement decreases on the affected side
- jugular venous pulse-indicates right heart failure
Palpation
For palpation, place both palms or medial aspects of hands on the posterior lung field. Ask the patient to count 1-10. The point of this part is to feel for vibrations and compare between the right/left lung field. If the pt has a consolidation (maybe caused by pneumonia), the vibration will be louder at that part of the lung. This is because sound travels faster through denser material than air.If there is pneumonia, palpation may reveal increased vibration and dullness on percussion. If there is pleural effusion, palpation should reveal decreased vibration and there will be 'stony dullness' on percussion.
- Tracheal deviation - check whether trachea is in centre line.
- Tactile fremitus - the patient says boy-O-boy or ninety-nine, whilst physician sense with ulnar aspect of hand for changes in sound conduction.
- Respiratory expansion - check whether expansion is equal
- Location of apex beat - check if there has been deviation of heart
Percussion
On percussion, you are testing mainly for pleural effusion or pneumothorax. The sound will be more tympanic if there is a pneumothorax because air will stretch the pleural membranes like a drum. If there is fluid between the pleural membranes, the percussion will be dampened and sound muffled.Middle finger strikes the middle phalanx of the other middle finger. The sides of the chest are compared.
- dullness indicates consolidation
- hyper-resonance (as can be simulated by percussing the inflated cheek) suggests a pneumothoraxPneumothoraxPneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
(can be related to COPDChronic obstructive pulmonary diseaseChronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...
or a pleural effusionPleural effusionPleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.-Pathophysiology:...
) - diaphragmatic excursionDiaphragmatic excursionDiaphragmatic excursion is the movement of the thoracic diaphragm during breathing.Normal diaphragmatic excursion should be 3–5 cm, but can be increased in well-conditioned persons to 7–8 cm. This measures the contraction of the diaphragm....
- normal is 3 to 6 cm.
Auscultation
Lung auscultation is listening to the lungs bilaterally at the anterior chest and posterior chest. Wheezing is described as a musical sound on expiration or inspiration. It is the result of narrowed airways. Rhonchi are bubbly sounds similar to blowing bubbles through a straw into a sundae. They are heard on expiration and inspiration. It is the result of viscous fluid in the airways. Crackles or rales are similar to rhonchi except they are only heard during inspiration. It is the result of alveoli popping open from increased air pressure.- Inspiratory crackles (decompensated congestive heart failureCongestive heart failureHeart failure often called congestive heart failure is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition...
) - Expiratory wheezes (asthmaAsthmaAsthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, emphysemaEmphysemaEmphysema is a long-term, progressive disease of the lungs that primarily causes shortness of breath. In people with emphysema, the tissues necessary to support the physical shape and function of the lungs are destroyed. It is included in a group of diseases called chronic obstructive pulmonary...
) - StridorStridorStridor is a high pitched wheezing sound resulting from turbulent air flow in the upper airway. Stridor is a physical sign which is produced by narrow or obstructed airway path. It can be inspiratory, expiratory or biphasic . Inspiratory stridor is common...
and other upper airway sounds - Bronchial vs. vesicular breath sounds
- Appropriate ratio of inspiration to expiration time (expiration time increased in COPD)
External links
- Respiratory exam - University of FloridaUniversity of FloridaThe University of Florida is an American public land-grant, sea-grant, and space-grant research university located on a campus in Gainesville, Florida. The university traces its historical origins to 1853, and has operated continuously on its present Gainesville campus since September 1906...
- Exam of the chest - University of Florida
- Respiratory exam - Respiratory Exam
- Lung sounds online - Emory University School of MedicineEmory University School of MedicineEmory University School of Medicine, a component of Emory’s Robert W. Woodruff Health Sciences Center, is ranked among the nation’s institutions for biomedical education and research...