PHYSICAL DIAGNOSIS OF THE RESPIRATORY SYSTEM CNS lesions (cerebrum –

SYMPTOM voluntary)
v Complaints reported by the patient CNS lesions (pons – Ø Ondine’s Curse – relies
v Subjective involuntary) on voluntary breathing; no
SIGN involuntary breathing
v Findings by the medical professional center
v Objective Anxiety Myasthenia Gravis
ASA poisoning Narcotic overdoses
PATTERNS OF BREATHING Hypoxemia Obesity (extreme)
v EUPNEA Pain
Ø Normal, regular, and comfortable at a rate of 12 – 20 cpm
v TACHYPNEA SIGNS AND SYMPTOMS
Ø Fast breathing at a rate of > 20 cpm DYSPNEA
Ø May be abnormal and physiologic v Difficulty in breathing
v BRADYPNEA v Labored breathing
Ø Slow breathing at a rate of < 12 cpm v Shortness of breath
Ø Most often abnormal v Commonly observed in pulmonary or cardiac compromise
v HYPERPNEA v In general, it ­ c severity of underlying disease
Ø Another term for tachypnea but is deeper
Ø Hyperventilation, deep breathing QUESTIONS TO ASK
• May cause fainting Ø Is it present even when the patient is resting?
Ø > 20 cpm Ø How much walking? On a level surface? Up stairs?
v SIGHING • Climb up 2 flights of stairs s SOB at normal pace (4 – 5
Ø Frequently interspersed deeper breath kph)
v AIR TRAPPING Ø Is it necessary to stop and rest even when climbing stairs?
Ø Increasing difficulty in getting breath out • Blood supply to parts of the body is not enough to meet
Ø Asthma (problem of expiration) and COPD demand
v BIOT • Also ask about dizziness (insufficient blood supply to
Ø Irregularly interspersed periods of apnea in a disorganized the brain)
sequence of breaths Ø What other activities precipitate it? What level of physical
Ø Not really metabolic; Sometimes a brain problem demand?
v CHEYNE-STOKES
• Have tendency to adjust their level of function
Ø Varying periods of increasing depth interspersed with apnea
v ATAXIC
FORMS
Ø Usually something neural
v Othopnea
Ø Significant disorganization with irregular and varying
Ø SOB that begins or ­ when the patient lies down
depths of respiration
• Heart is too weak; Lungs get filled by blood that cannot
v KUSSMAUL
Ø Rapid, deep, labored be pumped by the heart
Ø Acidic • Comfortable in sitting position since gravity can help the
heart to pump blood
Ø Quantified by the number of pillows needed to lie down
comfortably
Ø Sign of heart failure; MEDICAL EMERGENCY
v Paroxysmal Nocturnal Dyspnea
Ø A sudden onset of SOB after a period of recumbency
• Onset of CHF or Pulmonary Edema is after a few hours
• Heart is not as weak as in orthopnea
Ø Sitting upright is helpful
v Platypnea
Ø SOB that begins or increases when the patient is upright
Ø Something is compressing the heart
Ø Not a common presentation
v Trepopnea
Ø SOB that is pronounced on sidelying
Ø Ex. When only 1 lung is working; Collapsed Lung; Tumor

10 P’s OF DYSPNEA OF RAPID ONSET

Pneumonia Pericardial Tamponade
Ø > 50 mL of fluid inside
pericardial sac
Ø Compression of heart
Pneumothorax Pump Failure (Heart Failure)
Pulmonary Constriction / Peak Seekers (high altitudes)
Asthma
Peanut (foreign body) Psychogenic
Pulmonary Embolus Poisons

COUGH
v Common symptom of a respiratory problem
v Causes may be related to localized or more general insults at any
point in the respiratory tract
INFLUENCES ON THE RATE AND DEPTH OF BREATHING v May be voluntary or reflexive response to an irritant
INCREASES DECREASES
SEQUENCE OF EVENTS
Acidosis (metabolic) 1. Usually preceded by a deep inspiration
Alkalosis (metabolic)
Ø Expel CO2 to ­ ph of blood 2. Closure of glottis
3. Contraction of chest, abdominal, and pelvic muscles
4. Sudden spasmodic expiration (forces open the closed glottis) v Etiology
5. Air and secretions are exhaled Ø Extrapleural Air
• Pneumothorax
SPUTUM Ø Fluid
v Generally associated with cough • Accumulate and compress on lungs
v In more than small amounts and with any degree of consistency Ø Mass
always suggests the presence of disease • Ex. Tumors or Granuloma
v Sputum characteristics may give a clue to some causes of sputum
RETRACTIONS
SOME CAUSES OF SPUTUM / HEMOPTYSIS v Suggest an obstruction to inspiration at any point in the
CAUSES POSSIBLE SPUTUM CHARACTERISTICS respiratory tract
Yellow, green, rust (blood mixed c yellow v Intrapleural pressure becomes increasingly negative
BACTERIAL
sputum), clear or transparent; blood v Degree and level of retractions depend on the extent and level of
INFECTION
streaked; mucoid; viscid obstruction
Mucoid, viscid, Blood streaked (not
VIRAL INFECTION
common) UPPER AIRWAY LOWER AIRWAY INFRAGLOTTIC
All of the above; particularly abundant in OBSTRUCTION OBSTRUCTION OBSTRUCTION
CHRONIC
early morning; slight, intermittent, blood Inspiratory Stridor Stridor tends to be Stridor tends to be
INFECTIOUS
streaking; occasionally, large amounts of (expiratory severe) quieter louder, rasping
DISEASE
blood Muffling voice (“hot Hoarse voice;
CARCINOMA Slight, persistent blood streaking Hoarse cough or cry potato in mouth”); Swallowing not
INFARCTION Blood clotted; large amounts of blood or barking cough Dysphagia; No affected; Cough is
TUBERCULOUS cough harsh, barking
Large amounts of blood
CAVITY Awkward position of
Head positioning is
Alar flaring head and neck to
not a factor
BREATH: CLUES BEHIND THE SMELL preserve airway
SMELL POSSIBLE CAUSES Retraction at the
Sweet, fruity Diabetic Ketoacidosis; Starvation Ketosis suprasternal notch
Fishy, stale Uremia cyanosis
Ammonia-
Uremia PERIPHERAL SIGNS
like
Musty fish, Fetor hepaticus; Hepatic failure; Portal vein; v Cyanosis: lips, nails
clover Thrombosis; Postcaval shunts v Pursing: lips
Foul, v Clubbing: finger nails
Intestinal obstruction, diverticulum v Alar flaring: air hunger
feculent
Nasal/sinus pathology; Infection; Foreign body; (esp. alveolar
Foul, putrid Cancer; Respiratory infections; Empyema; Lung involvement)
Abscess Bronchiectasis v Suggest Cardiac or pulmonary difficulty
Tonsillitis; Gingivitis; Respiratory Infections;
Halitosis AUSCULTATION
Vincent Angina; Gastroesophageal Reflux; PUD
v With a stethoscope
Cinnamon PTB
v Provides important condition of the lungs and pleura
v Breath sounds:
PHYSICAL EXAMINATION
Ø Intensity
INSPECTION
Ø Pitch
GENERAL IMPRESSION
Ø Quality
v Position
Ø Duration
Ø Tripod Position
• Has trouble breathing SEQUENCE
• Helps circulate blood to the lungs
v Color
Ø Color of the lips
v Mental Status
v Ability to speak
v Respiratory Effort

THORACIC CONTOUR
v Chest will not be absolutely symmetric
v AP < Transverse diameter (> 0.70 – 0.75)
Ø ­ c age
v Barrel Chest
Ø Chronic Asthma
Ø Emphysema
Ø Cystic Fibrosis
v Pectus Excavatum
Ø Heart might have been displaced
v Pectus Carinatum
v Kyphosis
v Scoliosis
v Kyphoscoliosis

SYMMETRY NORMAL BREATH SOUNDS

CHEST ASYMMETRY VESICULAR – air sacs
v Unequal expansion and respiratory compromised caused by: v Heard over most of the lungs
Ø Collapsed lung v Low pitch
Ø Limitation of expansion v Soft and short expiration
• May be brought about by problems c thoracic cage v More prominent in thin individuals or children
Ø Restrictive Pulmonary Lung Disease v Diminished in overweight or muscular individuals
BRONCHOVESICULAR – tubes and air sacs PALPATION
v Heard over the main bronchus area and over upper ® posterior v Thoracic Expansion
lung field v Crepitus
v Medium pitch Ø Crackly or crinkly
v Expiration equals inspiration sensation, a gentle
and bubbly feeling
BRONCHIAL / TRACHEAL (TUBULAR) Ø Indicates air in the
v Heard only over trachea subcutaneous
v High pitch tissue from
v Loud and long expirations, sometimes a bit longer than inspirations • Rupture
somewhere in
the respiratory
system
• By infection from gas-producing organism
Ø May be localized or generalized
Ø Subcutaneous Emphysema – air under skin
v Pleural Friction Rub
Ø Palpable, coarse, grating vibration
Ø Usually on inspiration
Ø Feel of leather rubbing on leather
Ø Ex. Pleuritis
v Tactile Fremitus
Ø Palpable vibration of chest wall that results from speech or
other verbalizations
ADVENTITIOUS BREATH SOUNDS nd
Ø Best felt parasternally at the 2 ICS at the level of
FINE CRACKLES
bifurcation of bronchi
v High-pitched, discrete,
Ø 99, tres-tres, Mickey Mouse
discontinuous crackling at the end
of inspiration
DECREASED INCREASED
v Not cleared by cough
v Ex. Pneumonia, CHF, Chronic Excess air in lungs Presence of fluids within the
Bronchitis, Asthma, and other Emphysema lungs
obstructive diseases Pleural thickening / effusion Tumors
Massive pulmonary edema Lung compressions
MEDIUM CRACKLES Bronchial obstruction Lung consolidations
v Lower, moist sound Heavy bronchial secretions
v During mid-stage of inspiration
v Not cleared by cough

COARSE CRACKLES
v Loud, bubbly noise
v Hear during inspiration
v Not cleared by cough
v Ex. Pulmonary edema and fibrosis

RHONCHI
v Sonorous wheeze, snore-like PERCUSSION
v Loud, low, coarse sounds PERCUSSION TONES OVER THE CHEST
v Most often heard continuously Type of Tone Intensity Pitch Duration Quality
during inspiration or expiration
Resonant Loud Low Long Hollow
v Coughing may clear the sound
Flat Soft High Short Very dull
(mucus accumulation in trachea or
Dull Medium Medium Medium Dull thud
large bronchi)
v Ex. Narrowed airway disease to high
(asthma) Tympanic Loud High Medium Drum-like
Hyperresonant Very loud Very low Longer Booming
WHEEZE
v Sibilant wheeze
v Musical noise like a squeak
v Most often heard continuously
during inspiration or expiration
v Usually louder during expiration
v Ex. Obstructive disease; Bronchitis

PLEURAL FRICTION RUB

v Dry, rubbing, or grating usually caused by inflammation of pleural
surfaces
v Heard during
inspiration or
expiration
v Loudest over
lower lateral
anterior
surface
v Ex. Pleurisy
(inflammation
of pleural
surfaces)
 DIAGNOSTIC MODALITIES FOR THE RESPIRATORY SYSTEM OBSTRUCTIVE VS. RESTRICTIVE DEFECT
PULMONARY FUNCTION TESTS PARAMETER OBSTRUCTIVE RESTRICTIVE
v AIRWAY FUNCTION FVC (N) or ¯ ¯
Ø Simple spirometry FEV1 ¯ ¯
Ø Forced Vital Capacity Maneuver FEF25-75 ¯ (N) or ¯
Ø Maximal Voluntary Ventilation
FEV1/FVC ¯ ­
Ø Maximal Inspiratory / Expiratory Pressures
Ø Airway resistance TLC (N) or ¯ ¯
v LUNG VOLUMES AND VENTILATION
Ø Functional Residual Capacity BODY PLETHYSMOGRAPHY
Ø Total lung capacity, residual volume v The most accurate
Ø Minute ventilation, alveolar ventilation, dead space
Ø Distribution of ventilation
v DIFFUSING CAPACITY TESTS
v BLOOD GASES AND GAS EXCHANGE
Ø Blood gas analysis
Ø Pulse oximetry
Ø Capnography
v CARDIOPULMONARY EXERCISE TESTS
v METABOLIC MEASUREMENTS
Ø Resting Energy Expenditure
Ø Substrate Utilization
v CHEMICAL ANALYSIS OF EXHALED BREATH

SPIROMETRY
v Measurement of the pattern of air movement into and out of the
lungs during controlled ventilatory maneuvers
v Often done as a maximal expiratory maneuver PULSE OXIMETRY
v Simple, office-based v Inaccurate readings
v Measures flow, volumes
v Volume vs. Time
v Can determine:
Ø Forced Expiratory Volume in 1 second (FEV1)
Ø Forced Vital Capacity (FVC)
Ø FEV1/FVC
Ø Forced Expiratory Flow 25% - 75% (FEF25-75)

INDICATIONS
v Detect disease
v Evaluate extent and monitor course of disease
v Evaluate treatment
v Measure effects of exposures
v Assess risk for surgical procedures

PARAMETERS PEAK FLOW METER

v FVC v Measures peak expiratory flow rate
Ø Total volume expired
Ø Volume parameter
v FEV1
Ø Volume expired in 1 second
Ø Flow parameter
v FEV1/FVC
Ø Ratio of FEV1/FVC
Ø Flow parameter
v FEF25-75
Ø Flow rate at 25% - 75% of FVC
Ø Flow parameter
CAPNOMETRY
PATTERNS OF VENTILATORY DYSFUNCTION SEEN ON v Continuous waveform monitoring or capnography
SPIROMETRY v Colorimetric devices