Earlier, we discussed about Fever and General clinical history taking format. Today, it is going to be respiratory system! Respiratory system is one of the most examined organ system in clinical postings and clinical practice. Apart from asking question and answers to the patient for the history, we should be able to perform a well organized examination of the patient so that we do not miss a single point.
In today’s version of respiratory system examination,we will go step-wise to reveal the importance of every aspect. For convenience, respiratory system has been divided into two parts- Upper respiratory tract involving nasal cavity, nasopharynx, sinsuses, oropharynx, larynx and Lower respiratory tract consisting of trachea, lobar bronchus, segmental bronchus, alveolar sac, generations of tracheobronchial tree.
We will discuss about Rule of Four- Inspection, Palpation, Percussion and Auscultation.
Patient can present with any of the following chief complaints, after which you have to decide you are going to examine respiratory system for further clinical questions and answers:-
- Chest pain
- Heaviness in chest
- Hoarseness of voice
- Swelling of feet (associated with heart sound 3,i.e,HS3, Ascites and Hepatomegaly will point to Cor pulmonale)
- Epistaxis, Sinusitis,i, Running nose, Sneezing
- Syncope, Bone pain, Fatigue, Altered mentation
- General- Loss of appetite or weight (may mean cancer), Sleep, Fatigue, Bladder, Bowel
Other Important Signs
Other important signs from the patient are never to be missed, for they hold significant value in respiratory system examination:
- DECUBITUS(position of patient on bed)- Tripod sitting position can hint towards respiratory discomfort
- CYANOSIS- may indicate severe respiratory distress
- CLUBBING- may indicate chronic lung disease
- PULSE- bradycardia and tachycardia
- FACE (eg. Cushingoid due to steroids or moon face in Superior vena cava syndrome)
- LYMPHADENOPATHY- may indicate infection or cancer
- JUGULAR VENOUS PRESSURE (JVP)
- PERIPHERAL OEDEMA
- SWOLLEN CALF- Deep venous thrombosis from calves can cause pulmonary embolism
Upper Respiratory Tract Examination
- NOSE- Congestion, Discharge (Rhinorrhoea), Hypotrophied turbinates, Bleeding spots, Polyps, Deviated nasal septum, Alae nasae for nasal flare,i.e, nostrils widening
- MOUTH- Mouth breathing (eg.Adenoids) or purse lip respiration as seen in Chronic Obstructive Pulmonary Disease
- AIR SINUSES- Check tenderness over maxillary, ethmoidal and frontal sinuses (can’t check for sphenoid)
- PHARYNX- Check throat, gum, teeth, posterior pharyngeal wall, post nasal drip (person feels like cough in his throat due to accumulation of mucus in throat), nasopharynx, tonsils, halitosis (bad breath from mouth)
- LARYNX- Not checked physically, may require laryngoscopy
Lower Respiratory Tract Examination
We follow the four rule of- Inspection (observation without touching), Palpation (touching and feeling), Percussion (tapping fingers) and Auscultation (using the stethoscope).
So first one goes as:
- Shape of chest- Inspect patient in standing as well as lying down position. Check for Symmetry, Barrel shaped chest (seen in severe COPD and asthma), Pigeon chest (Pectus carinatum), Funnel chest (Pectus excavatum), Kyphosis, Scoliosis, Lordosis.
- Movement of chest- Notice symmetry (decreased movement on a side can mean lung collapse), paradoxical inward motion of abdomen during respiration.
- Apical impulse- seen in tangential view over precordium.
- Respiration- check the following for respiration:
- Rate- Normal rate in adults is 14-18, in children- 14-25 and approximately 40 in newborns. Respiration rate over 20 can mean Tachypnoea and below 10 can mean Bradypnoea.
- Rhythm- Breathing pattern by movement of chest. It can be Normal, Irregularly irregular (Biot’s), Regularly regular (Cheyne-stokes ,i.e, apnoea for 30 seconds after periods of hyperpnoea), or Miscellaneous like Kussmaul, Stertorous, Prolonged inspiration and Prolonged expiration.
- Type- Respiration can be Thoracic (predominantly in females due to more use of chest muscles), Abdominal (predominantly in males), Abdomino-thoracic, Paradoxical respiration (seen in diaphragmatic palsy, patient’s abdomen comes out in expiration.
- Depth- It can be Normal, Shallow (seen in narcotic poisoning) or Deep (Hyperpnoea, Hyperventilation, eg. in metabolic acidosis.
- Pattern- Wheeze (expiratory), Stridor (inspiratory), Shallow breathing, Mouth breathing, Sighing (deep inspiration-pause-deep expiration, Gasping (dying breath), Purse lip respiration.
- Venous prominence over chest.
- Fullness (Unilateral/Bilateral) or Depression (Localized/Generalized.
- Supraclavicular and infraclavicular fossa.
- Level of nipples- Same or not?
- Use of Accessory muscles- Sternomastoid and Scaleni.
- Wheeze or stridor.
- Intercostal space suction.
- Skin- look front and back for :-
- Front- Gynaecomastia, Pigmentation, Swelling, Oedema
- Back- Scoliosis, Kyphosis, Dropping of shoulder, Winging of scapula, Symmetry of intrascapular areas and Venous prominence
Place your palm and fingers to palpate over regions for:
- Surface temperature
- Tenderness over chest
- Position over trachea and tracheal rug (finger placed on trachea moves inferiorly with each respiration as seen in COPD)
- Chest expansion- Put your hand on front of chest, so the thumbs lie on sternum and fingers beneath axilla, and ask patient to breath(decreased movement of thumb on one side can mean lung collapse)
- Apex beat
- Vocal fremitus- Place palm on trachea and ask patient to say 123
- Tactile fremitus- Place palm over regions of chest and ask patient to say 123
- Pleural rub if palpable- feels like friction such as in pleurisy
Place the pleximeter finger (index finger) of one hand and tap it with index finger of other hand and notice the resonance over regions of intercostal spaces and clavicle (only index finger may be used to tap the clavicle).
There may be Dullness or Hyper-resonance:
- Causes of Dullness- Consolidation, Pneumonia, Tuberculosis, Atelectasis, Hemothorax, Empyema
- Causes of Hyper-resonance- Pneumothorax, Emphysema, Chronic obstructive pulmonary disease
Place stethoscope over regions of chest and auscultate for:
- Breath sounds- Vesicular, Bronhchial, Bronchovesicular.
- Vocal resonance- increased or decreased, Whispering pectorilquy (increased loudness of whispering during auscultation), Aegophony (E to A transition due to solidification of lung)
- Adventitious sounds- Abnormal sounds such as Rhonchi, Crepitations, Wheeze, Stridor, Pleural rub (like hairs rubbing).