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.

References

  1. Colin D. Selby (25 October 2002). Respiratory medicine: an illustrated colour text. Elsevier Health Sciences. pp. 14–. ISBN   978-0-443-05949-0.
  2. 1 2 Bickley, Lynn S.; Szilagyi, Peter (2017). Bates' Guide to Physical Examination and History-Taking. Wolters Kluwer. p. 317. ISBN   978-1469893419.
  3. Bickley & Szilagyi 2017, p. 335.
  4. "Blue discoloration of the skin: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2019-08-30.
  5. 1 2 3 Tuteur, Peter G. (1990), Walker, H. Kenneth; Hall, W. Dallas; Hurst, J. Willis (eds.), "Chest Examination", Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.), Butterworths, ISBN   9780409900774, PMID   21250209 , retrieved 2019-08-30
  6. "Kyphosis (Roundback) of the Spine - OrthoInfo - AAOS". www.orthoinfo.org. Retrieved 2019-08-30.
  7. "Scoliosis - Symptoms and causes". Mayo Clinic. Retrieved 2019-08-30.
  8. "Do you have a rounded, bulging chest?". Mayo Clinic. Retrieved 2019-08-30.
  9. "Pectus excavatum - Symptoms and causes". Mayo Clinic. Retrieved 2019-08-30.
  10. "Pectus carinatum - Symptoms and causes". Mayo Clinic. Retrieved 2019-08-30.
  11. Gallo de Moraes, Alice; Surani, Salim (2019-01-15). "Effects of diabetic ketoacidosis in the respiratory system". World Journal of Diabetes. 10 (1): 16–22. doi: 10.4239/wjd.v10.i1.16 . ISSN   1948-9358. PMC   6347653 . PMID   30697367.
  12. Rudrappa, Mohan; Bollu, Pradeep C. (2019), "Cheyne Stokes Respirations", StatPearls, StatPearls Publishing, PMID   28846350 , retrieved 2019-08-30
  13. "Why People Get Chest Retractions". WebMD. Retrieved 2019-08-30.
  14. 1 2 3 4 5 6 7 8 9 10 Bickley, Lynn S.; Szilagyi, Peter G. (2003). Bates' guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN   0781735114. OCLC   49527040.
  15. 1 2 3 "Lung examination". meded.ucsd.edu. Retrieved 31 August 2019.
  16. Palaniappan R, Sundaraj K, Ahamed NU, Arjunan A, Sundaraj S. Computer-based Respiratory Sound Analysis: A Systematic Review. IETE Tech Rev 2013;30:248-56
  17. Malik, Nazish; Tedder, Brandon L.; Zemaitis, Michael R. (2020), "Anatomy, Thorax, Triangle of Auscultation", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30969656 , retrieved 2021-12-14
  18. Reyes, Felix M.; Le, Jacqueline K. (2020), "Lung Exam", StatPearls, StatPearls Publishing, PMID   29083650 , retrieved 2021-12-14
  19. Bickley & Szilagyi 2017, p. 323.
  20. "Wheezing". WebMD. Retrieved 2019-08-31.
  21. Reichert, Sandra; Gass, Raymond; Brandt, Christian; Andrès, Emmanuel (2008-05-16). "Analysis of Respiratory Sounds: State of the Art". Clinical Medicine. Circulatory, Respiratory and Pulmonary Medicine. 2: 45–58. doi:10.4137/ccrpm.s530. ISSN   1178-1157. PMC   2990233 . PMID   21157521.
  22. "Lung Sounds: What Do They Mean?". WebMD. Retrieved 2019-08-31.
  23. "default - Stanford Children's Health". www.stanfordchildrens.org. Retrieved 2019-08-31.