Respiratory assessment

1. Respiratory
and Cardiac Assessment
Dr. Deepesh Sharma(PT)
Assistant Professor
JNU College Of Physiotherapy ,Jaipur

2. INTRODUCTION
• The aim of assessment is to define the
patient's problems accurately.
• It is based on both a subjective and an
objective assessment of the patient.
• Without an accurate assessment it is
impossible to develop an appropriate plan of
treatment.

3. • Problem oriented medical system (POMS) first
described by Weed in 1968.
• This system has three components:
1. Problem oriented medical records (POMR)
2. Audit
3. Educational programme.

4. POMR
• The POMR is now widely used as the method
of recording the assessment, management
and progress of a patient.
• It is divided into five sections
1. Database
2. Problem list
3. Initial plan and goals
4. Progress notes
5. Discharge summary

5. DATABASE
• The database contains a concise summary of
the relevant information about the patient
taken from the medical notes, together with
the subjective and objective assessment made
by the physiotherapist.
• The format may differ from hospital to
hospital, but will contain the same
information.

6. • The first part contains the patient's personal
details including name, date of birth, address,
hospital number, and referring doctor.
• It may also contain the diagnosis and reason
for referral.
• The second part summarizes the history from
the medical notes and the physiotherapy
assessment.
• This is often divided into several sections

7. • History of presenting condition (HPC)
summarizes the patient's current problems,
including relevant information from the
medical notes.
• Previous medical history (PMH) summarizes
the entire list of medical and surgical
problems that the patient had in the past.
• It may be written in disease-specific groupings
or as a chronological account.

8. • Drug history (OH) is a list of the patient's current
medications (including dosage) taken from the
medication charts.
• Drug allergies should also be noted.
• Family history (FH) includes a list of any major
diseases suffered by members of the immediate
family.

9. • Social history (SH) provides a picture of the patient's
social situatio
• The layout of the patient's home should also be
ascertained with particular emphasis on stairs.
• Occupation and hobbies, both past and present, give
further information about the patient's lifestyle.
• Finally, history of smoking and alcohol use should be
noted.

10. • Patient examination includes all information
collected in the physiotherapist's subjective and
objective assessment of the patient.
• Test results contain any significant findings as they
become available.
• These may include arterial blood gases, spirometry,
blood tests, sputum analysis, chest radiographs,
computerized tomography (CT) and any other
relevant tests.

11. Subjective assessment
• Subjective assessment is based on an interview with
the patient.
• It should generally start with open-ended questions -
What is the main problem?
What troubles you most?
• Allowing the patient to discuss the problems that are
most important to him at that time.
• As the interview progresses, questioning may
become more focused on those important features
that need clarification.

12. • There are five main symptoms of respiratory disease:
• Breathlessness (dyspnoea)
• Cough
• Sputum and haemoptysis
• Wheeze
• Chest pain.

13. • With each of these symptoms, enquiries should be
made concerning:
1. Duration - both the absolute time since first
recognition of the symptom (months, years) and the
duration of the present symptoms (days, weeks)
2. Severity - in absolute terms and relative to the
recent and distant past
3. Pattern - seasonal or daily variations
4. Associated factors - including precipitants, relieving
factors, and associated symptoms, if any.

14. Breathlessness
• Breathlessness is the subjective awareness of an
increased work of breathing.
• It is, the predominant symptom of both cardiac and
respiratory disease.
• It also occurs in anaemia where the oxygen-carrying
capacity of the blood is reduced, in neuromuscular
disorders where the respiratory muscles are affected,
and in metabolic disorders where there is a change in the
acid-base equilibrium or metabolic rate (e.g.
hyperthyroid disorders).
• Breathlessness is also found in hyperventilation
syndrome where it is due to psychological factors (e.g.
anxiety).

15. Duration and Severity
• The duration and severity of breathlessness is most
easily assessed through enquiries about the level of
functioning in the recent and distant past.
• Comparison of the severity of breathlessness
between patients is difficult because of differences in
perception and expectations.
• To overcome these difficulties, numerous tradings
have been proposed, The New York Heart
Association grading (1964)

16. The New York Heart Association classification of
breathlessness(1964)
• Class I No symptoms with ordinary activity, breathlessness
only occurring with severe exertion, e.g. running up hills, fast
bicycling, cross-country skiing
• Class II Symptoms with ordinary activity, e.g. walking up
stairs, making beds, carrying large amounts of shopping
• Class III Symptoms with mild exertion, e.g. bathing,
showering, dressing
• Class IV Symptoms at rest

17. • Breathlessness is usually worse during exercise and better
with rest The one exception is hyperventilation syndrome
where breathlessness may improve with exercise.
• Two patterns of breathlessness have been given specific
names:
• Orthopnoea is breathlessness when lying flat.
• Paroxysmal nocturnal dyspnoea (PND) is breathlessness that
wakes the patient at night In the cardiac patient, lying flat
increases venous return from the legs so that blood pools in
the lungs, causing breathlessness.
• A similar pattern may be described in patients with severe
asthma, but here the breathlessness is caused by nocturnal
bronchoconstriction.

18. Cough
• Coughing is a protective reflex which rids the airways of secretions
or foreign bodies.
• Any stimulation of receptors located in the pharynx, larynx, trachea,
or bronchi may induce cough.
• Important .features concerning cough are its effectiveness, and
whether it is productive or dry.
• The severity of cough may range from an occasional disturbance to
a continual trouble.
• A loud, barking cough, which is often termed 'bovine', may signify
laryngeal or tracheal disease.
• Recurrent coughing after eating or drinking is an important
symptom of aspiration.
• A chronic productive cough every day is a fundamental feature of
chronic bronchitis and bronchiectasis.

19. • Interstitial lung disease is characterized by a
persistent dry cough.
• Nocturnal cough is an important symptom of
asthma, in children, and young adults, but in older
patients ,it is more commonly due to cardiac failure.
• Postoperatively, the strength and effectiveness cough
is important for the physiotherapist to assess.

20. Sputum
• In a normal adult, approximately 100 ml of
tracheobronchial secretions are produced daily and
cleared subconsciously.
• Sputum is the excess tracheobronchial secretions
that is cleared from the airways by coughing or
huffing.
• It may contain mucus, cellular debris,
microorganisms, blood and foreign particles.

21. Miller grading (1963)
• M1 mucoid with no suspicion of pus
• M2 predominantly mucoid, suspicion of pus
• PI 1/3 purulent, 2 /3 mucoid
• P2 2/3 purulent 1/3 mucoid
• P3 > 2 / 3 purulent

22. • Questioning should determine the colour,
consistency and quantity of sputum produced each
day.
• This may clarify the diagnosis and the severity of
disease

23. Sputum analysis

24. • in clinical practice sputum is often classified as
mucoid, mucopurulent or purulent, together with an
estimation of the volume.
• Haemoptysis is the presence of blood in the sputum
It may range from slight streaking of the sputum to
frank blood.

25. Chest pain
• In respiratory patients chest pain usually originates from
musculoskeletal, pleural or tracheal inflammation, as the lung
parenchyma and small airways contain no pain fibres.
• Pleuritic chest pain is caused by inflammation of the parietal
pleura, and is usually described As a severe, sharp, stabbing
pain which is worse on inspiration. It is not reproduced by
palpation.
• Tracheitis generally causes a constant burning pain in the
centre of the chest aggravated by breathing.
• Musculoskeletal (chest wall) pain may originate from the
muscles, bones, joints or nerves of the thoracic cage. It is
usually well localized and exacerbated by chest and/or arm
movement. Palpation will usually reproduce the pain.

26. • Pericarditis may cause pain similar to angina or
pleurisy.
• Angina pectoris is a major symptom of cardiac
disease. Myocardial ischaemia characteristically
causes a dull central retrosternal gripping or band-
like sensation which may radiate to either arm, neck
or jaw.

27. Other symptoms
• Fever (pyrexia)
• Headache
• Peripheral edema
• Reduce Functional ability

28. Peripheral oedema
• Suggests right heart failure which may be due
to cor pulmonale (right ventricular failure
secondary to hypoxic pulmonary
vasoconstriction).
• Peripheral oedema may also occur in patients
taking high-dose corticosteroids, as a result of
salt and water retention.

30. Edema grading

31. General observation
• Examination starts by observing the patient from the end of
the bed.
• In the intensive care patient there are a number of further
features to be observed.
• The level of ventilatory support must be ascertained.
• This includes both the mode of ventilation and the route of
ventilation.
• The level of cardiovascular support should also be noted,
including drugs to control blood pressure and cardiac output,
pacemakers and other mechanical devices.
• The patient's level of consciousness should also be noted.

32. • Any patient with a decreased level of consciousness is at risk of aspiration
and retention of pulmonary secretions.
• In those patients who are not pharmacologically sedated, the level of
consciousness is often measured using the Glasgow Coma Scale.
• This gives the patient a score (from 3 to 15) based on his best motor,
verbal and eye responses.

33. Glasgow Coma Scale
Eye opening
• Spontaneous 4
• To speech 3
• To pain 2
• None 1
Verbal ronsponse
• Oriented 5
• Confused speech 4
• Inappropriate words 3
• Incomprehensible sounds 2
• None 1
Motor response
• Obeys commands 6
• Localizes to pain 5
• Withdraws (generalized) 4
• Flexion 3
• Extension 2
• No response 1

34. Observation of the chest
• The oblique fissure, dividing the upper and middle lobes from the
lower lobes, runs underneath a line drawn from the spinous process
of T2 around the chest to the 6th costochondral junction anteriorly.
• The horizontal fissure on the right dividing the upper lobe from the
middle lobe, runs from the 4th intercostal space at the right sternal
edge horizontally to the midaxillary line, where it joins the oblique
fissure.
• The diaphragm sits at approximately the 6th rib anteriorly, the 8th rib
in the midaxillary line, and the 10th rib posteriorly.
• The trachea bifurcates just below the level of die manubriosternal
junction.
• The apical segment of both upper lobes extends 2.5 cm above the
clavicles.

35. Observation of the chest
• The chest should be symmetrical with, the ribs, in
adults, descending at approximately 45° from the
spine.
• The transverse diameter should be greater than the
anteroposterior (AP) diameter.
• The thoracic spine should have a slight kyphosis.

36. Chest Abnormalities
• Kyphoscoliosis
• Pectus excavatum
• Pectus carinatum
• Barrel chest

37. Thorax of a normal adult
• The anteroposterior chest diameter is smaller than
lateral diameter.

38. Barrel chest
• A transverse section of thorax (left); a torso (right) with
signs of barrel chest (increased anteroposterior
diameter)

39. Pectus Excavatum (funnel chest)
• A transverse section of thorax (left); a torso (right) with signs
of pectus excavatum (depression of the lower portion of
sternum)

40. Pectus Carinatum (pigeon chest)
• A transverse section of thorax (left); a torso (right) with signs
of pectus carinatum (increased anteroposterior chest
diameter, anteriorly displaced sternum, and depression of the
costal cartilages)

41. Thoracic Kyphoscoliosis
• A transverse section of thorax (left); a torso (right) with signs
of kyphoscoliosis (abnormal spinal curvatures and vertebral
rotation).

42. Breathing pattern
• The approximate ratio of inspiratory to expiratory time ( I
: E ratio) is 1:1.5 to 1:2.
• Prolonged expiration
• Pursed-lip breathing
• Apnoea
• Hypopnoea
• Kussmaul's respiration
• Cheyne Stokes respiration
• Ataxic breathing
• Apneustic breathing

43. Breathing (Chest)Biomechanics
• Pump handle movement
• Bucket handle movement

45. Intercostal indrawing
• It occurs where the skin between the ribs is drawn inwards
during inspiration.
• It may be seen in patients with severe inspiratory airflow
resistance.
• Larger negative pressures during inspiration suck the soft
tissues inwards.
• This is an important sign of respiratory distress in children, but
is less often seen in adults.

46. Palpation of the chest
Trachea
• First the trachea is palpated to assess its position in relation to the sternal
notch.
• Tracheal deviation indicates underlying mediastinal shift.
• The trachea may be pulled towards a collapsed or fibrosed upper lobe, or
pushed away from a pneumothorax or large pleural effusion.

48. Chest expansion
• This can be assessed by observation, but palpation is
more accurate.
• The patient is instructed to expire slowly to residual
volume.
• At residual volume the examiner's hands are placed
spanning the posterolateral segments of both bases,
with the thumbs touching in the midline posteriorly.
• The patient is then instructed to inspire slowly and the
movement of both thumbs is observed.
• Both sides should move equally, with 3-5 cm being the
normal displacement.

50. Paradoxical breathing
• It is where some or all of the chest wall moves inwards on inspiration
and outwards on expiration.
• It can involve anything from a localized area to the entire chest wall.
• Localized paradox occurs when the integrity of the chest wall is
disrupted.
• Fractures of multiple ribs with two or more breaks in each rib will
result in the central section losing the support usually provided by
the rest of the thoracic cage.
• Thus, during inspiration, this loose segment (often called a 'flail
segment') is drawn inwards as the rest of the chest wall moves out.
• In expiration the reverse occurs.

51. Paradoxical breathing
• Paradoxical movement of one hemithorax may be remarkably
difficult to observe.
• It may be caused by unilateral diaphragm paralysis.
• Paradox of the entire chest wall occurs in bilateral diaphragm
weakness or paralysis.
• It is most apparent when the patient is supine.
• Paradoxical movement of the lower chest can occur in patients with
severe chronic airflow limitation who are extremely hyperinflated.
• As the dome of the diaphragm cannot descend any further,
diaphragm contraction during inspiration pulls the lower ribs
inwards.
• This is called 'Hoover's sign'.

52. Surgical emphysema
• Air in the subcutaneous tissues of the chest, neck or
face should also be noted.
• On palpation there is a characteristic crackling in the
skin.
• This occurs when a pneumomediastinum (air in the
mediastinum) has tracked outwards.

53. Tactile vocal fremitus
• It is the measure of speech vibrations transmitted through the
chest wall to the examiner's hands.
• Vocal fremitus is increased when the lung underneath is
relatively solid (consolidated), as this transmits sound better.
• As sound transmission is decreased through any interface
between lung and air or fluid, vocal fremitus is decreased in
patients with a pneumothorax or a pleural effusion.

54. Tactile vocal fremitus
• Typically, tactile vocal fremitus is increased over
areas of consolidation and decreased over pleural
effusion in the case of lung collapse.
• Place your hands at the lower anterior part of the
chest with the hypothenar (ulnar) sides of each hand
touching the chest at the same level on the right and
left.
• Ask the patient to say "99" or "1-2-1". The vibration
felt against your hand should be the same in each
hand.

55. tactile vocal fremitus

57. Percussion
• It is performed by placing the left hand firmly on the chest
wall so that the fingers have good contact with the skin.
• The middle finger of the left hand is struck over the distal
interphalangeal joint with the middle finger of the right hand.
• The right wrist should be relaxed so that the weight of the
entire right hand is transmitted through the middle finger.
• Both sides of the chest from top to bottom should be
percussed alternately, paying particular attention to the
comparison between sides.

58. Percussion
• Resonance is generated by the chest wall vibrating over
the underlying tissues.
• Normal resonance is heard over aerated lung, whilst
consolidated lung sounds dull, and a pleural effusion
sounds 'stony duIl.
• Increased resonance is heard when the chest wall is
free to vibrate over an air-filled space, such as a
pneumothorax or bulla.
• In situations where the chest wall is unable to move
freely, as may occur in obese patients, the percussion
note may sound dull, even if the underlying lung is
normal.

59. Auscultation
• Chest auscultation is the process of listening to and
interpreting the sounds produced within the thorax.
• A stethoscope simplifies auscultation and facilitates
localization of any abnormalities.
• It consists of a diaphragm and bell connected by tubing to two
ear-pieces.
• The diaphragm is generally used for listening to bream
sounds, whilst the bell is best for the very low frequencies
generated by the heart (especially the third and fourth heart
sounds).

60. Breath sounds
• Breath sounds can be classified into two categories, either NORMAL
or ABNORMAL (adventitious).
• Breath sounds originate in the large airways where air velocity and
turbulence induce vibrations in the airway walls.
• These vibrations are then transmitted through the lung tissue and
thoracic wall to the surface where they may be heard readily with the
aid of a stethescope.
• Normal breath sound production is directly related to air flow velocity
and airway lumen architecture.

61. Bronchial sound
• Bronchial breath sounds are hollow, tubular sounds that
are higher pitched compared to vesicular sounds.
• They can be auscultated over the trachea and larynx
where they are considered normal.
• There is a distinct pause in the sound between
inspiration and expiration. I:E ratio is 1:3 .
• Otherwise, bronchial sounds heard over the thorax
suggest lung consolidation and pulmonary disease.
• Pulmonary consolidation results in improved
transmission of breath sounds originating in the trachea
and primary bronchi that are then heard at increased
intensity over the thorax.

62. Bronchial sound

63. Bronchovesicular
• Inspiration to expiration periods are equal.
• These are normal sounds in the mid-chest area or in the
posterior chest between the scapula.
• They reflect a mixture of the pitch of the bronchial breath
sounds heard near the trachea and the alveoli with the
vesicular sound.
• They have an I:E ratio of 1:1.
• Increased intensity of bronchovesicular sounds is most
often associated with increased ventilation or pulmonary
consolidation.

64. Bronchovesicular

65. Vesicular
• Vesicular breath sounds are soft and low pitched with a
rustling quality during inspiration and are even softer
during expiration.
• These are the most commonly auscultated breath
sounds, normally heard over most of the lung surface.
• They have an inspiration/expiratory ratio of 3 to 1 or I:E
of 3:1.
• Increased intensity may be associated with pulmonary
consolidation.

66. Vesicular

67. Adventitious sounds
1. Crackles - Fine (Rales)
2. Crackles - Coarse (Rales)
3. Wheeze
4. Rhonchi - Low Pitched Wheezes
5. Pleural Rubs

68. Crackles - Fine (Rales)
• Fine crackles are brief, discontinuous, popping lung sounds that are
high-pitched.
• Fine crackles are also similar to the sound of wood burning in a
fireplace, or hook and loop fasteners being pulled apart or
cellophane being crumpled.
• Crackles, previously termed rales, can be heard in both phases of
respiration.
• Early inspiratory and expiratory crackles are the hallmark of chronic
bronchitis.
• Late inspiratory crackles may mean pneumonia, CHF, or atelectasis.

69. Crackles - Fine (Rales)

70. Crackles - Coarse (Rales)
• Coarse crackles are discontinuous, brief, popping lung
sounds.
• Compared to fine crackles they are louder, lower in pitch
and last longer.
• They have also been described as a bubbling sound.
• You can simulate this sound by rolling strands of hair
between your fingers near your ear

71. Crackles - Coarse (Rales)

72. Wheeze
• Wheezes are adventitious lung sounds that are continuous
with a musical quality.
• Wheezes can be high or low pitched.
• High pitched wheezes may have an auscultation sound similar
to squeaking.
• Lower pitched wheezes have a snoring or moaning quality.
• The proportion of the respiratory cycle occupied by the
wheeze roughly corresponds to the degree of airway
obstruction.
• Wheezes are caused by narrowing of the airways.

73. Wheeze

74. Rhonchi - Low Pitched Wheezes
• Low pitched wheezes (rhonchi) are continuous, both
inspiratory and expiratory, low pitched adventitious lung
sounds that are similar to wheezes.
• They often have a snoring, gurgling or rattle-like quality.
• Rhonchi occur in the bronchi.
• Sounds defined as rhonchi are heard in the chest wall where
bronchi occur, not over any alveoli.
• Rhonchi usually clear after coughing.

75. Rhonchi - Low Pitched Wheezes

76. • Pleural rubs are discontinuous or continuous, creaking or grating sounds.
• The sound has been described as similar to walking on fresh snow or a
leather-on-leather type of sound.
• Coughing will not alter the sound.
• They are produced because two inflamed surfaces are sliding by one
another, such as in pleurisy.
• During auscultation, pleural rubs can usually be localized to a particular
place on the chest wall.
• They also come and go.
• Because these sounds occur whenever the patient's chest wall moves,
they appear on inspiration and expiration.
• Pleural rubs stop when the patient holds her breath.
• If the rubbing sound continues while the patient holds a breath, it may be
a pericardial friction rub.

78. Other test
• Exercise capacity
• Spirometry
• Arterial blood gases
• Chest radiographs

79. CONCLUSION
• Accurate assessment should reveal the exact
nature of the patient's problems and delineate
those that physiotherapy can improve.
• Only then can the best treatment be chosen
for patient.
• Subsequent reassessment is essential to
ensure that treatment is specific, effective and
efficient.
• This process ensures high-quality patient care.

80. References
• “Physiotherapy for Respiratory and Cardiac
Problems” by Jennifer A Pryor Barbara A
Webber .
• Easy Auscultaion
• Physiotherapy in chest ,Heart and Vascular
disease by Cash