Assessment of patient with respiratory disorder

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2. Session objectives
General guidelines for thorax and lungs examination
General Assessment
Pertinent Subjective Data
Equipment for Examination
Physical examination of Thorax and lungs
Inspection
Palpation
Percussion
Auscultation
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3.  At the end of this session you will be able to :
 Take a history of patient with respiratory problems
 Describe subjective datum of patient with respiratory
problems
 Perform physical assessment of patient with
respiratory problems
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4. Physical setup
- Quiet, warm , well-lit and equipped room.
- Full medical instrument (stethoscope must)
Position :-
- Supine - for examination of anterior chest.
- Sitting- for examination of posterior chest.
Exposure:- chest above waist ,but in female patient
drape the anterior chest while examining the posterior.
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5. Cont’d...
Sitting - examine posterior thorax and lungs.
– The pt’s arms should be folded across the chest. So
that the scapula moves partly out of the way and
increasing your access to the lung fields.
Supine- examine anterior thorax & lungs.
– Easier to examine women b/c the breasts can be
gently displaced and wheezes, if present are more
likely to be heard.
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6. Stethoscope
Ruler – 15cm.
Tape measure
Washable marker
Alcohol swabs
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7. • Cough
• Shortness of breath
• Wheezing
• Chest pain with
breathing
• History of respiratory
infections
• Smoking history
• Blood-streaked sputum
(hemoptysis)
• Environmental exposure
• Self-care behaviors
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8. Cough:
• Forced expulsive action against an initially closed glottis
• Acute cough –
– lasting < 3 weeks,
– Most common in acute viral URTI
– Self-limiting and benign
– May have 'red flag' symptoms (Haemoptysis ,
Breathlessness (Fever ,Chest pain & Weight loss)
• Chronic cough > 8 weeks.
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9. Disease Type of cough
Severe asthma or
chronic COPD-
Prolonged wheezy coughing
Lung cancer Non-explosive 'bovine' cough with hoarseness
Laryngeal
inflammation,
infection and tumour
Harsh, barking or painful and associated with
hoarseness and the rasping or croaking inspiratory
sound of stridor.
Bronchial infection
and bronchiectasis
Moist cough
Chronic bronchitis Persistent moist 'smoker's cough‘ in the morning
Pneumonia Dry, centrally painful and non-productive cough.
Asthma May have a paroxysmal dry cough after a viral
infection that may last several months (bronchial
hyper-reactivity).
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10. Timing and associated features of cough
Nocturnal cough Common in asthma
A chronic cough that lessens during
weekends and holidays
Occupational asthma and exposure to
dusts and fumes
Daytime cough Occult gastro-oesophageal reflux
disease (GERD) and chronic sinus
disease
Dry cough after medication Angiotensin-converting enzyme (ACE)
inhibitors
Coughing during and after swallowing
liquids
Neuromuscular disease of oropharynx
Large purulent sputum to be coughed
up, varying with posture
Bronchiectasis
Sudden large amounts of purulent
sputum on a single occasion
Rupture of a lung abscess or empyema
Large volumes of watery sputum with a
pink tinge in an acutely breathless
Pulmonary oedema
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11. Types of sputum
Type (4) Appearance Cause
Serous Clear, watery Acute pulmonary oedema
Frothy, pink Alveolar cell cancer
Mucoid Clear, grey Chronic bronchitis/COPD
White, viscid Asthma
Purulent Yellow Acute bronchopulmonary
infection
Asthma (eosinophils)
Green Longer-standing infection
Pneumonia
Bronchiectasis
Cystic fibrosis
Lung abscess
Rusty Rusty red Pneumococcal pneumonia11

12. Types of sputum…
• Signs, which vary from blood-stained sputum to a large,
sudden hemorrhage
• The most common causes are:
– Pulmonary infection
– Carcinoma of the lung
– Abnormalities of the heart or blood vessels
– Pulmonary artery or vein abnormalities
– Pulmonary embolus and infarction
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13. • Looking for general signs of respiratory diseases
:-
i. inspection
ii. Palpation
iii. Percussion and
iv. Auscultation.
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14. A. General Appearance
I. Look for pattern of Breathing:-
 Respiratory rate
 Normal (14-20 x/min).
 Abnormalities;-
 Tachypnea = RR > 20/min,
e.g. lung infection (pneumonia, P.TB…)
 Bradypnea= RR<12/min,
e.g. increased ICP, diabetic coma…
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15. Cont’d...
Rhythm:
• Normal - regular & quite
• Abnormalities;-
 Rapid and shallow
 Causes, metabolic acidosis (DKA), exercise,
anxiety…
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16. II. Watch for sign of respiratory distress
 use of respiratory accessory muscles ( sternoclediomastoid
& trapizus –during inspiration ,and abdominal muscles –
during expiration).
• Signs of respiratory distress:-
- contraction of SCM
- IC & SC, retraction
- Sub costal retraction
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17. III. Listen for
• Stridor:- audible harsh sound during inspiration.
– Upper air way obstruction.
- Wheeze:- audible harsh sound during expiration.
Audible both to the patient and to others.
• Wheezing - partial airway obstruction from secretions,
tissue inflammation, or a foreign body.
– Bronchial asthma
– Viral pneumonia
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18. IV) Assess the patient’s colour for cyanosis:-
• Is subtle bluish discoloration of mucous membranes of
mouth, lips and nail beds.
• Cyanosis signals:-
i. Hypoxia.
ii. Clubbing of the nails in COPD or
iii. Congenital heart disease
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19. Two types.
1) Central cyanosis:- inadequate gas exchange in the lungs
resulting in a significant reduction in arterial oxygenation.
• It occurs if oxygen saturation < 80%, or 2 to 3 g of
unsaturated Hgb/100 ml of blood.
• It results from primary pulmonary problems ,or other
conditions
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E.g. Pulmonary edema
,asthma, COPDS, very sever
pneumonia, pulmonary
fibrosis
 Inspecting- Lips and tongue.

20. 2) peripheral cyanosis: results from an excessive
extraction of oxygen at the periphery.
- Is due to increased oxygen extraction in states of low
cardiac output . e.g. Shock, exposure to cold…
Is seen in nail beds ,toes and nose
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21. V) Finger clubbing:-
• Curving, roundness & ,thickening of finger nails.
• Resulted from deposition of soft tissue in nail beds
due to hyper plastic response for hypoxemia.
e.g Lung abscess, bronchiectasis, empyma…..
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22. 
 Examination is done by inspecting finger nails ,and it
includes grading of the clubbing.
Grade – 1:- fluctuation of nail bed.
Grade – 1I:- obliteration of angle of nail bed.
Grade – III:-Increased curvature of nail
Grade – 1V:- drum stick appearance
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23. Inspect the neck:-
• During inspiration,
– Contraction of the sternomastoid or other accessory
muscles, or supraclavicular retraction
– Trachea midline- lateral deviation in pneumothorax,
pleural effusion, or atelectasis
• shape of the chest
Anteroposterior (AP) increase - aging &COPD.
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24. 24
Abnormal shapes:
I . Pectus carnitum (pigeon chest) –protrusion of sternum and
costal cartilages anteriorly.
– Increasing the AP diameter.
– Costal cartilage adjacent to the sternum is depressed.
Causes:- Congenital, or ricket

25. II. Pectus excavatum (Funnel chest):
• Depression in the lower portion of the sternum.
• So the heart & great b/vs are compressed causing murmurs.
• Cause can be rickets /congenital.
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26. III . Barrel chest : - a chest with increased A-P Diameter.
• Normal shape during infancy.
• Cause: COPDs
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27. IV). Thoracic kyposcoliosis
• Abnormal spinal curvatures & vertebral rotation deforming
the chest.
• Elevated scapulae, s-shaped spine.
• Interrupts lung function.
• Causes can be :-osteoporosis, skeletal disorders
V) Flail chest
• Is an unstable chest resulting when multiple ribs are
fractured.
• So that it interferes with respiration.
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28. B. Chest movement;- (symmetrical/ asymmetrical)
- Normally: Symmetrical
- Abnormal (asymmetric);
-Causes:- Unilateral lagging – due to pneumonic
consolidation, pleural effusion, pneumothorax,
atelectasis (Collapse),pulmonary fibrosis.
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29. II. Palpation
A. Position of trachea.
• Placing the index & third finger at sternoclavicular joint
on clavicle and feeling for its position with the middle
finger.
• Normally - central to slightly shifted to the Rt
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30. Displacement of trachea & causes
Towards side of lesion
• Lung fibrosis
• Collapse (atelectasis)
Away from side of lesion
• Pleural effusion
• Pneumothorax
• Hemothorax
• Lung mass
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31. B. Pain & tenderness.
Causes of tenderness:
- Over inflamed pleura (Pleuritis)
- Over fractured rib
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32. C. Chest expansion (symmetrical/ asymmetrical)
- Placing the hands at costal margins with making skin fold at
the center with thumbs,
- Asking the patient to inhale and exhale & looking for
symmetry of separation of thumbs.
• Normally – symmetrically
• Abnormalities
– Unilateral reduction of chest expansion.
– causes: pleural effusion, pneumothorax, collapse,
consolidation and fibrosis.
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33. 33
Posterior chest
-Place both hands Posteriorly at the
level of T9 or T10.
-Slide hands medially to pinch a small
amount of skin between your thumbs.
-Observe for symmetry as the patient
exhales fully following a deep
inspiration.
Anterior chest
-Placing the hands at costal margins
with making skin fold
Asking to inhale and exhale & looking
for symmetry of separation of thumbs.

34. D. Feeling Tactile Fremitus (palpable vibrations)
• Speech creates vibrations &When one palpates the chest
wall these vibrations can be felt and are termed tactile
fremitus
• provides useful information about the density of the
underlying lung tissue and chest cavity.
• Asking the patient to say “99” ,or in “amharic” “arba-
arat (44)”
• Feel the vibration with the ball (bony part) of palm of
the hand.
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36. Palpation sequence for tactile fremitus: posterior thorax
(left) and anterior thorax (right).
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37. 37

38. Causes of asymmetry in tactile
fremitus
Increased
• Conditions that increase
the density of the lung
and make it more solid
• E.g. Pneumonia
(consolidation)
,atelectasis , lung masses
Decreased
• States that decrease the
transmission of these
sound waves
• E.g. Pleural effusion,
pneumothorax ,obesity ,
thick chest wall
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39. III. Percussion:
• Tapping on the chest wall and determining the
nature of underlying structure.
– Air filled, fluid –filled or solid
To identify level of diagrammatic dullness.
To estimate diaphragmatic excursion.
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40. Percussion Cont’d...
-
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41. • Percussion of the
posterior thorax
• In sitting position, --
symmetric areas
• Percussed at 5-cm
intervals.
• Progression starts at
the apex of each lung
and
• concludes with
percussion of each
lateral chest wall.
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42. Percussion Cont’d...
• Hyper extended the middle finger of your left hand.
• Press the hyper extended finger distal interphalangeal
joint on the surface to be percussed avoid surface
contact by any other part of the hand as it dumps the
vibrations.
• Position your right forearm close to the surface in the
hand cocked upward.
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43. Percussion Cont’d...
 With a quick, sharp, but relaxed wrist motion strike the
hyper extended finger with the tip of the partially right
middle finger.
 You should use always lightest percussion that produces
a clear note a thick chest wall requires heavier
percussion than a thin one.
 Constantly compare two sides.
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44. 44
Sites
• Causes of abnormal percussion note
- Stony dull percussion note , due to pleural effusion, lung
mass….
-Relative dullness, due to pneumonia, collapse, fibrosis…..
- Hyperresonance, can be due to, pneumothorax,
emphysema…..

45. Percussion findings notes
Percussion notes Normal Abnormal
Flat Thigh Massive pleural effusion,
tumor
Dull Liver Lobar pneumonia, pleural
effusion, hemothorax
Resonance Normal lung
tissue
Chronic bronchitis
Hyper-resonance Emphysema.
Bronchial asthma.
Pneumothorax.
Tympani Puffed out
checks,
abdomen
Large pnemothorax
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46. Diaphragmatic excursion(descent of the diaphragms).
• Normal resonance of the lung stops at the diaphragm.
• Position of the diaphragm is different during
inspiration and expiration.
• Determining the distance between the level of
dullness on full expiration and the level of dullness
on full inspiration.
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47. Techniques :
• Holding the pleximeter finger above & parallel to the
expected level of dullness
• Instructs to take a deep breath & hold it while the maximal
descent of diaphragm is percussed.
• Percuss downward in progressive steps until dullness clearly
replaces resonance.
• Point at w/c percussion note at the midscapular line changes
from resonance to dullness is marked with a pen.
• Then, instructed to exhale fully and hold it while again
percusses downward to the dullness of the diaphragm and
mark this point.
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48. Techniques ….
• Distance between the two markings indicates the range of
motion of the diaphragm.
• Max. Excursion 8 - 10 cm ( healthy, tall men )
• For most people 5 -7 cm .
• Normally, about 2 cm higher on the right
• Decreased diaphragmatic excursion
• Pleural effusion and emphysema.
• Increase in intra-abdominal pressure, as in
• Pregnancy,
• Obesity, or
• Ascites,
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49. • Technique of determining diaphragmatic excursion.
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50. • To identify lung sounds.
• Objectives of chest auscultation is to asses air entry in to
lungs.
– Normally – good air entry bilaterally.
– Abnormalities
• Unilateral decreased air entry,
– Pleural effusion, lung collapse, pneumonia,
pneumothorax ,foreign body/mass in air way…
• Bilateral decrement of air entry
– Emphyema, thick chest wall
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51. There are four types of normal breath sounds
• Tracheal
• Bronchial
• Bronchovesicular
• Vesicular
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52. 52

53. Normal breath sounds….
Vesicular breath sounds
• Soft, low-pitched
• Heard over most of the
lung fields
• Longer inspiratory than
expiratory component
• No pause b/n expiration
and inspiration
• Heard through inspiration
and 1/3rd of expiration.
Bronchial breath sounds
• Loud and high pitched like
air rushing through a tube.
• Louder expiratory
component
• Over maniuburium of
sternum
• Over lung field is a sign of
pneumonic consolidation.
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54. Normal breath sounds….
Bronchovesicular breath
sounds
• Mixture of bronchial and
vesicular sounds
• Equal inspiratory and
expiratory components length.
• Silent gap b/n inspiration &
expiration
• Heard in the 1st & 2nd
interspaces anteriorly & b/n
scapulas Posteriorly
Tracheal breath
sounds
• Very loud, harsh
sounds
• Over the trachea in
the neck.
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55. Added(adventitious) sounds:-
• Abnormal sounds heard during auscultation and sign of
respiratory pathologies
• There are four types of adventitious sounds:-
- Crackles (Crepitations /rales)
- Wheezes
- Rhonchi
- Pleural rubs
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56. I. Crackles (crepitations /rales):-
• Short, discontinuous, nonmusical sounds heard
mostly during inspiration.
- Can be coarse ,or fine in quality.
 Coarse crackles(crepitations): are bubbling sound
produced by bubbling of air through secretions.
- causes- pneumonia, bronchiectasis, pulmonary
cavities….
Fine crackles: produced by explosive reopening of
narrowed peripheral air ways during inspiration.
- Cause, pulmonary edema ,CHF….
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57. II. Wheezes
• Are continuous, musical, high-pitched sounds heard
Mostly during expiration.
• Airflow through narrowed bronchi.
• This narrowing may be due to swelling, secretions,
spasm, tumor, or foreign body.
• Wheezes are commonly associated with the
bronchospasm of asthma.
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58. iii. Rhonchi
• Are lower-pitched, more sonorous lung sounds.
• They are believed to be more common with transient
mucus plugging and poor movement of airway
secretions.
iv) Stridor
• Is a wheeze that is entirely or predominately
inspiratory.
• Indicate partial obstruction of the larynx or trachea.
• Is a medical emergency.
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59. v. pleural rub
• Is a grating sound produced by motion of the pleura,
which is impeded by frictional resistance.
• It is best heard at the end of inspiration and at the
beginning of expiration.
• Pleural rubs are heard when pleural surfaces are
roughened or thickened by inflammatory or neoplastic
cells or by fibrin deposits.
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60. Transmitted voice sounds
• As sound vibrations produced in the larynx are
transmitted to the chest wall as they pass through the
bronchi & alveolar tissue,
– The sounds are diminished in intensity & altered so that
syllables are not distinguishable.
• If you hear abnormally located broncho-vesicular breath
sounds or bronchial breath sounds,
– Continue on to assess transmitted voice sounds done in
the following ways:-
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61. a. Bronchophony
Ask to say “99, or 44” or “
– Normally the sounds transmitted through the chest
wall are muffled & indistinct/not distinguishable.
– Louder, clear voice sounds heard through the
stethoscope / bronchophony/ suggests that air filled
lung has become airless.
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62. b. Egophony
Ask the pt to say’’ ee’’.
– Normally a muffled long “E” sound heard.
– When “ee” is heard as ‘’ay’’----- Egophony.
– Suggests that the lung has been changed to airless.
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63. c. Whispered pectoriloquy
Ask the pt to whisper “ninety –nine or “one, two, three”.
– Normal faintly & indistinct whispered voice heard.
– Louder clear whispered sounds / whispered
pectoriloquy/ suggest airless lung.
N.B:- Increased transmission of voice sounds
suggest that air filled lung has become airless. Ex.
Pneumonia
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64. Diagnostic assessments
 Pulmonary Function Tests
 Arterial Blood Gas Studies
 Pulse Oximetry
 Cultures
 Sputum Studies
 Imaging Studies
 Chest X-Ray
 Computed Tomography
 Magnetic Resonance
Imaging
 Fluoroscopic Studies
 Pulmonary Angiography
 Biopsy
 Endoscopic Procedures
– bronchoscopy,
– thoracoscopy,
– thoracentesis.
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