Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Professional Skills Review Respiratory System Prepared by: Ali JassimAlhashli Based on: Macleod’s Clinical Examination; 13th Ed

2. History • Cough: • Acute (> 3 weeks; resolves spontaneously): most common cause is Upper Respiratory Tract Infection (URTI). If stridor is noticed with acute cough this might be due to croup or acute epiglottitis. • Chronic (< 8 weeks): • In a non-smoker who has a normal chest x-ray: Gastro-Esophageal Reflux Disease (GERD). • Wheezy cough: asthma or Chronic Obstructive Pulmonary Disease (COPD). • Cough especially in the morning with sputum: chronic bronchitis. • Cough which is associated with hemoptysis, fever and night sweats: tuberculosis (TB). • Hoarsness: • It occurs due to damage to the left recurrent laryngeal nerve (you have to consider lung cancer as a differential diagnosis).

3. History • Wheeze: it is a whistling sound which is produced when air passes through narrowed airways during expiration (this is found with asthma and COPD). When a wheeze is heart using a stethoscope it is called “ronchi”. • Stridor: a harsh inspiratory sound due to turbulent airflow through a partial obstruction of upper airway (this is found with croup). • Sputum: • Mucus produced by the respiratory tract (normally amount = 100 ml/day; normal color: clear). • Types of sputum: • Clear or mucoid= acute pulmonary edema and COPD (without and active infection). • Purulent (consisting of pus): • Yellow = acute Lower Respiratory Tract Infection (LRTI) and asthma. • Green: COPD (with an active infection) and cystic fibrosis. This green color is caused by verdoperoxidase enzyme from neutrophils. • Rusty red: pneumococcal pneumonia.

4. History • Hemoptysis: • Coughing-up blood from the respiratory tract. • Types: • Blood-streaked clear sputum: suspect lung cancer. • Hemoptysis with purulent sputum: suggesting an infection. • Shortness of Breath (SOB or dyspnea): • Considered to be normal with: strenous physical exercise. • Causes: • Non-cardiac: psychogenic, obesity and anemia. • Cardiac: heart failure, mitral valve disease and cardiomyopathy. • Respiratory: foreign body aspiration, asthma, COPD, pneumonia, TB, tumor, pneumothorax and pulmonary effusion. • Orthopnea: • SOB when lying flat. • Most cases suggest: left-sided heart failure.

5. History • Paroxysmal Nocturnal Dyspnea (PND): • SOB wakening patient from sleep. • Found with: left-sided heart failure and asthma. • Pleural chest pain: • It is sharp, stabbing and increases with inspiration. • Conditions: pneumonia, pulmonary embolism and pneumothorax. • Respiratory pattern: • Respiratory Rate (RR): • Normal: 12-16 breaths/ minute. • Tachypnea: < 25 breaths/ minute. Tachypnea occurs with asthma, COPD, pulmonary edema and pneumonia. • Breathing patterns: • Hyperventilation: • It is common with anxiety and emotional distress. • It is associated with hypocarbia (↓PaCO2) and alkalosis that can eventually result in tetany and even seizure. • Rapid-deep breathing (Kussmaul breathing) is a characteristic of Diabetic Ketoacidosis (DKA). • Apnea (absence of breathing): • Obstructive sleep apnea is characterized by: loud snoring, a pause of breathing, grunting and then restoration of snoring.

6. Physical Examination of Respiratory System • Position of the patient: 45 degrees on bed with exposure of chest and upper abdomen. • Always start by washing your hands, making sure of privacy, introduce yourself to the patient, explain for him what are you going to do and take permission. • Then, comment on the general appearance of the patient: • Is patient conscious and alert (to time, place, person)? • Is he lying comfortably on bed? • Is he in pain or has toxic-appearance? • Is he in respiratory distress? (this is represented by: nasal flaring, cyanosis, retractions and use of accessory muscles which occurs with severe asthma and COPD exacerbation). Cyanosis is the bluish discoloration which occurs when deoxygenated Hb< 50 g/L and it can be: • Central: when arterial oxygen saturation > 90%. • Peripheral: represented by bluish discoloration of fingers and toes due to circulation disorders or cold. • Is he obese or cachexic? • Is he connected to any devices? (such as: pulse oximetry, ECG leads, pressure cuff, IV line or nasal cannula).

7. Physical Examination of Respiratory System • Then, you have to take the vital signs which include: • Pulse: • Measure it from radial artery (by placing 2-3 fingers over it and counting beats in 30 seconds then multiply it by 2). • Normal = 60-100 beats/ minute. If less than 60: bradycardia; if more than 100: tachycardia. • You have to comment on: rate, rhythm, volume and character (volume and character are best determined from carotid artery). • Respiratory Rate (RR): • Count it in 60 seconds (= 1 minute) while checking for pulse (normal = 12-16 breaths/minute) and pay attention to the pattern of breathing: • Females: thoraco-abdominal (because they rely on intercostal muscles). • Males: abdomino-thoracic (because they rely on diaphragm). • Blood Pressure (BP): • Ideal: 120/80 mmHg. • Hypertension: ≥ 140/90 • Hypotension: ≤ 90/60 • Temperature: normally within 36.5-37.5 C. Before checking temperature, you have to steralize the thermometer and then place it in the mouth, axilla or rectum.

8. Physical Examination of Respiratory System • After doing all what is mentioned previously, start your physical examination which is related to the respiratory system by general inspection (it is preferred that you start by inspecting the hands first): • Hands: • Clubbing of fingers: • Causes: • 70% are thoracic: lung cancer, cystic fibrosis and COPD. • Cardiovascular: cyanotic congenital heart disease and infective endocarditis. • GI: liver cirrhosis, Inflammatory Bowel Disease (IBD) and celiac disease. • When examining fingers, you are looking for the presence of Schamroth’s window between the two index fingers → if not present → there is clubbing. • Grades of clubbing: • I: fluctuation of nail bed. • II: loss of angle between nail and nail bed. • III: increased nail curvature. • IV: obvious clubbing.

9. Physical Examination of Respiratory System • After doing all what is mentioned previously, start your physical examination which is related to the respiratory system by general inspection (it is preferred that you start by inspecting the hands first): • Hands (continued): • Palmarerythema. • Peripheral cyanosis. • Brownish stain on fingers and nails in smokers which is caused by tar (NOT nicotine). • Fine tremors → occurs in asthmatic patients using β-agonists (in bronchodilators). • Flapping tremors → indicating CO2 retention (which occurs in patients with COPD). • Head: • Face: does it look puffy? • Eyes: • Conjunctiva: if it is pale, this indicated that the patient has anemia. • Sclera: if it is yellow (scleralicterus), this indicates that the patient has jaundice. • Nose: watch for nasal flaring (a sign of respiratory distress). • Lips and mouth: • Tobacco stain on lips or teeth? • Tongue: if it is red-beefy in appearance, this indicates the presence of anemia.. Look under the tongue for bluish discoloration that indicates central cyanosis.

10. Physical Examination of Respiratory System Peripheral cyanosis Palmarerythema Flapping tremor

11. Physical Examination of Respiratory System Puffy face Pale conjunctiva Jaundice Nasal flaring Red-beefy tongue Central cyanosis Tobacco staining

12. Physical Examination of Respiratory System • Neck: • Jugular Venous Pressure (JVP): • It is increased in right-sided heart failure and conditions in which there is increased intra-thoracic pressure such as tension pneumothorax and severe acute asthma. • Use of accessory muscles. • Cervical lymph nodes: submental, submandibular, anterior cervical, posterior cervical, preauricular, postauricular, occipital and supraclavicular. There are swollen with metastasis of lung cancer, lymphoma or infection (if they appear inflamed and tender). Enlarged cervical lymph nodes

13. Physical Examination of Respiratory System • Then move to specific physical examination which is relate to your system (respiratory system): • Thorax (always remember that you have to compare both sides of the chest and do your examination from front and back): • Inspection: • Chest shape: • Normal: chest is symmetrical; anterior-posterior diameter > lateral diameter. If AP diameter < lateral diameter → COPD (barrel chest). • Pectuscarinatum (pigeon chest): symmetrical horizontal grooves above costal margin are formed (known as Harrison’s sulci) → this condition is caused by poorly-controlled childhood asthma (in your differential diagnosis you have to consider: rickets/osteomalacia). • Pectusexcavatum (funnel chest): developmental deformity and patient is usually asymptomatic. • Is chest moving with respiration (comment on pattern of breathing). • Is there skin rash or discoloration? • Are there any scars (surgical marks) such as sternotomy or thoracotomy? • Hair distribution. • Are there any obvious masses?

14. Physical Examination of Respiratory System Pectusexcavatum Pectuscarinatum

15. Then move to specific physical examination which is relate to your system (respiratory system): • Thorax (always remember that you have to compare both sides of the chest and do your examination from front and back): • Palpation: • Trachea position: gently place your right index finger in suprasternal notch and palpate the trachea; slight deviation to the right is normal in healthy people. Deviation of trachea: • Toward the lesion: occurs with lung collapse or fibrosis. • Away from lesion: occurs with tension pneumothorax and massive pulmonary effusion. • Tracheal tug: 2-3 fingers distance between cricoid cartilage and suprasternal notch. If less → hyperinflation of the chest. • Chest expansion: place both of your hand firmly on the chest wall; extend your fingers around the sides of patient’s chest; thumbs should almost meet in the midline; ask patient to take a deep breath; normal distance between your two thumbs when chest is expanded ≥ 5 cm. • Reduced expansion on one side: pulmonary fibrosis, pneumothorax, pleural effusion and lung collapse. • Bilateral reduction of chest expansion: diffuse lung fibrosis and COPD. • Tactile fremitus: by using the palmar surface ob your both hands over patient’s chest or back; ask the patient to say 99 (or 44 in Arabic); with each time patient says 99 you have to palpate the chest (tactile fremitus is increased when there is consolidation/pneumonia). Physical Examination of Respiratory System

16. Physical Examination of Respiratory System Tracheal position Tactile fremitus Chest expansion

17. Then move to specific physical examination which is relate to your system (respiratory system): • Thorax (always remember that you have to compare both sides of the chest and do your examination from front and back): • Percussion: • The palm of your left hand on patient’s chest; fingers are separated; strike the center of middle phalanx of your left middle finger with the tip of your right middle finger by a loose swinging movement of the wrist. • Don’t forget to percuss clavicles directly by taping on them. • Patient must fold his arms across the front of his chest when you percuss his back (to move scapulas away). • Percussion sounds: • Resonant: normal lungs. • Hyperresonant: pneumothorax (sometimes this occurs with COPD due to hyperinflation of the lungs). • Dull: consolidation, lung collapse or pulmonary fibrosis. • Stony dull: pulmonary effusion or hemothorax. Physical Examination of Respiratory System

18. Then move to specific physical examination which is relate to your system (respiratory system): • Thorax (always remember that you have to compare both sides of the chest and do your examination from front and back): • Auscultation: • Ask patient to cough thus clearing his chest. Then, place the diaphragm of your stethoscope over his chest. Ask patient to breath deeply through his open mouth. • Auscultate the trachea → normally: bronchial breathing. What are the characteristics of bronchial breathing: • Equal during inspiration and expiration. • There is a pause between the two phases. • Auscultate the chest starting from apices of lungs and descending over both sides of the chest → normally: vesicular breathing but it is changed to bronchial type of breathing when there is a consolidation. • Diminished breathing sounds occurs with: • Lung collapse of pulmonary fibrosis. • Occlusion by a foreign body or a tumor. • Pleural effusion. • Pneumothorax. • Obesity (this is not a pathological condition). • Added sounds: • Crackles: pulmonary edema, pneumonia or bronchiectasis. • Wheeze: asthma, COPD or lung cancer. Physical Examination of Respiratory System

19. Physical Examination of Respiratory System Sites of percussion Sites of auscultation

20. Physical Examination of Respiratory System

21. At the end, don’t forget to check lower limbs for pitting edema and thank your patientGood Luck!