Respiratory examination

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Respiratory examination
Respiratory examn.jpg
Respiratory examination
Purposepart of physical exam(or when a respiratory problem is present)

A respiratory examination, or lung examination, is performed as part of a physical examination, [1] in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination.

Contents

The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation of respiratory sounds, normally first carried out from the back of the chest. [2]

Stages

After positioning in which the patient sits upright with their arms at the side, with the chest clear of clothing, the four stages of the examination can be carried out. In order to listen to the lungs from the back the patient is asked to move their arms forward to prevent the scapulae (shoulder blades) from obstructing the upper lung fields. These fields are intended to correlate with the lung lobes and are thus tested on the anterior (front) and posterior (back) chest walls. [2]

Inspection

The examiner then estimates the patient's respiratory rate by observing how many times the patient breathes in and out within the span of one minute. This is typically conducted under the pretext of some other exam, so that the patient does not subconsciously change their baseline respiratory rate, as they might do if they were aware of the examiner observing their breathing. Adults normally breathe about 14 to 20 times per minute, while infants may breathe up to 44 times per minute. [3]

After obtaining the patient's respiratory rate, the examiner looks for any signs of respiratory distress, which may include:

The anterior and posterior chest wall are also inspected for any abnormalities, which may include:

In addition to measuring the patient's respiratory rate, the examiner will observe the patient's breathing pattern:

The physician then typically inspects the fingers for cyanosis and clubbing.

Tracheal deviation is also examined.

Palpation

Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. [14]

Chest percussion

Percussion is the act of tapping on the surface of the body in order to assess the structures that lie beneath the skin.

Percussion and resonance (the quality and feeling of sound) are used to examine lung movement and possible lung conditions.

Specifically, percussion is performed by first placing the middle finger of one hand over the area of interest. The middle finger of the other hand is used to strike the last joint of the placed finger. Percussion is performed in a systematic matter, from the upper chest to the lower ribs, and resonance is compared between the left and right sides of the chest. This is done from the front and back of the thorax. [14]

Percussion over different body tissues results in five common "notes". [14]

  1. Resonance: Loud and low pitched. Normal lung sound. [15]
  2. Dullness: Medium intensity and pitch. Experienced with fluid. [14]
  3. Hyper-resonance: Very loud, very low pitch, and longer in duration. Abnormal. [14]
    • Hyper-resonance can result from asthma or emphysema
  4. Tympany: Loud and high pitched. Common for percussion over gas-filled spaces. [14]
  5. Flatness: Soft and high pitched.

Auscultation

Proper positioning of patient for adequate lung sounds from the back Physical Exam - Stethoscope.jpg
Proper positioning of patient for adequate lung sounds from the back

The areas of the lungs that can be listened to using a stethoscope are called the lung fields, and these are the posterior, lateral, and anterior lung fields. The posterior fields can be listened to from the back and include: the lower lobes (taking up three quarters of the posterior fields); the anterior fields taking up the other quarter; and the lateral fields under the axillae, the left axilla for the lingual, the right axilla for the middle right lobe. The anterior fields can also be auscultated from the front. [15] [16] An area of thinner musculature on the back where sounds may be more audible is called the triangle of auscultation. [17]

During auscultation, deep breaths are taken through the mouth and abnormal sounds listened for. [18] [19] Abnormal sounds include:

Lastly an assessment of transmitted voice sounds is performed.

Related Research Articles

<span class="mw-page-title-main">Rib cage</span> Bone structure of the thorax

The rib cage or thoracic cage is an endoskeletal enclosure in the thorax of most vertebrates that comprises the ribs, vertebral column and sternum, which protect the vital organs of the thoracic cavity, such as the heart, lungs and great vessels and support the shoulder girdle to form the core part of the axial skeleton.

<span class="mw-page-title-main">Heart murmur</span> Medical condition

Heart murmurs are unique heart sounds produced when blood flows across a heart valve or blood vessel. This occurs when turbulent blood flow creates a sound loud enough to hear with a stethoscope. The sound differs from normal heart sounds by their characteristics. For example, heart murmurs may have a distinct pitch, duration and timing. The major way health care providers examine the heart on physical exam is heart auscultation; another clinical technique is palpation, which can detect by touch when such turbulence causes the vibrations called cardiac thrill. A murmur is a sign found during the cardiac exam. Murmurs are of various types and are important in the detection of cardiac and valvular pathologies.

<span class="mw-page-title-main">Thorax</span> Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation, and occasionally during exhalation. They are usually heard only with a stethoscope. Pulmonary crackles are abnormal breath sounds that were formerly referred to as rales.

<span class="mw-page-title-main">Auscultation</span> Listening to the internal sounds of the body, usually using a stethoscope

Auscultation is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory and respiratory systems, as well as the alimentary canal.

<span class="mw-page-title-main">Pulmonology</span> Study of respiratory diseases

Pulmonology, pneumology or pneumonology is a medical specialty that deals with diseases involving the respiratory tract. It is also known as respirology, respiratory medicine, or chest medicine in some countries and areas.

At the end of pregnancy, the fetus must take the journey of childbirth to leave the reproductive mother. Upon its entry to the air-breathing world, the newborn must begin to adjust to life outside the uterus. This is true for all viviparous animals; this article discusses humans as the most-researched example.

Percussion is a technique of clinical examination.

<span class="mw-page-title-main">Abdominal examination</span> Physical examination of abdomen

An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination.

In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination.

<span class="mw-page-title-main">Flail chest</span> Medical condition

Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.

<span class="mw-page-title-main">Respiratory sounds</span> Medical condition

Respiratory sounds, also known as lung sounds or breath sounds, are the specific sounds generated by the movement of air through the respiratory system. These may be easily audible or identified through auscultation of the respiratory system through the lung fields with a stethoscope as well as from the spectral characteristics of lung sounds. These include normal breath sounds and added sounds such as crackles, wheezes, pleural friction rubs, stertor, and stridor.

Egophony is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. It is due to enhanced transmission of high-frequency sound across fluid, such as in abnormal lung tissue, with lower frequencies filtered out. It results in a high-pitched nasal or bleating quality in the affected person's voice.

<span class="mw-page-title-main">Triangle of auscultation</span>

The triangle of auscultation is a relative thinning of the musculature of the back, situated along the medial border of the scapula which allows for improved listening to the lungs.

Whispered pectoriloquy refers to an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields on a patient's torso.

<span class="mw-page-title-main">Muscles of respiration</span> Muscles involved in breathing

The muscles of respiration are the muscles that contribute to inhalation and exhalation, by aiding in the expansion and contraction of the thoracic cavity. The diaphragm and, to a lesser extent, the intercostal muscles drive respiration during quiet breathing. The elasticity of these muscles is crucial to the health of the respiratory system and to maximize its functional capabilities.

In medicine, Imaging Lung Sound Behavior with Vibration Response Imaging (VRI) is a novelty computer-based technology that takes the concept of the stethoscope to a more progressive level. Since the invention of the stethoscope by René-Théophile-Hyacinthe Laennec France in 1816, physicians have been utilizing lung sounds to diagnose various chest conditions. Today auscultation provides physicians with extensive information on the examination of the patient. The skills of the examiner however, vary, as seen in a clinical study that was conducted on the diagnosis of pneumonia in 2004.

The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart, lungs, belly and the blood vessels.

<span class="mw-page-title-main">Non-invasive procedure</span> Medical procedure involving no break in skin

A medical procedure is defined as non-invasive when no break in the skin is created and there is no contact with the mucosa, or skin break, or internal body cavity beyond a natural or artificial body orifice. For example, deep palpation and percussion are non-invasive but a rectal examination is invasive. Likewise, examination of the ear-drum or inside the nose or a wound dressing change all fall outside the definition of non-invasive procedure. There are many non-invasive procedures, ranging from simple observation, to specialised forms of surgery, such as radiosurgery. Extracorporeal shock wave lithotripsy is a non-invasive treatment of stones in the kidney, gallbladder or liver, using an acoustic pulse. For centuries, physicians have employed many simple non-invasive methods based on physical parameters in order to assess body function in health and disease, such as pulse-taking, the auscultation of heart sounds and lung sounds, temperature examination, respiratory examination, peripheral vascular examination, oral examination, abdominal examination, external percussion and palpation, blood pressure measurement, change in body volumes, audiometry, eye examination, and many others.

The pulmonary examination or respiratory examination is the portion of the physical examination where the physician examines the respiratory system for signs of disease. It is performed as a part of a complete physical examination, or the physician may choose to perform a focused respiratory exam. Classically, it is performed after the HEENT examination, and consists of four stages: inspection, palpation, percussion, and auscultation. If there are signs of respiratory disease, the physician may order additional tests including medical imaging, such as a chest X-ray or CT scan, or laboratory tests, such as a complete blood count.

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