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Slide 1
Assessment of the Respiratory
System
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Slide 2
Physical Assessment
Objectives
Structure
Symptoms of respiratory disease
General examination
Focussed examination
Assessing respiratory function
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Slide 3
Physical Assessment
Structure
Anatomy & physiology
Surface anatomy
§ Upper lobe
§ Lower lobe
¥ Middle lobe
Lung Function
§ Oxygenate blood
§ Remove CO2
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Slide 4
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Slide 5
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Slide 6
Physical Assessment
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Slide 7
Physical Assessment
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Slide 8
Physical Assessment
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Slide 9
Physical Assessment
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Slide 10
Physical Assessment
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Slide 11
Physical Assessment
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Slide 12
Physical Assessment
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Slide 13
Physical Assessment
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Slide 14
Physical Assessment
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Slide 15
Physical Assessment
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Slide 16
Physical Assessment
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Slide 17
Physical Assessment
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Slide 18
Physical Assessment
Symptoms of respiratory disease
Dyspnoea
§ Causes
§ Duration
§ Variability
§ Asthma
§ Severity
§ Orthopnoea & PND
§ Hyperventilation
§ Hypoxia
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Slide 19
Physical Assessment
Symptoms of respiratory disease
Cough
Sputum
Haemoptysis
Pain
Wheeze & Stridor
Other body systems
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Slide 20
Physical Assessment
Overview
General Appearance
Cough & abnormal
sounds
Hands, Face & Neck
Inspect chest
Palpation
Percussion
Auscultation
Contemplation
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Slide 21
Physical Assessment
General Appearance
Bedside clues
Watch respiration
Speech
Cough &
abnormal sounds
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Slide 22
Physical Assessment
General Examination
First impressions
§ Clubbing
§ Cyanosis
¥ Central cyanosis
¥ Peripheral cyanosis
§ Tremors
§ Pulse & blood pressure
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Slide 23
Physical Assessment
Respiratory Signs
Chest movement with respiration
Rate of respiration (12-15/min)
Air entry - symmetrical? reduced?
Vocal Resonance?
Percussion note - resonant, dull
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Slide 24
Physical Assessment
Hands Face and Neck
Skin temperature
Tar staining
Cyanosis
Finger clubbing
Pulse
Tremor
Blood pressure
JVP
Nose
Eyes
Lymph nodes
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Slide 25
Physical Assessment
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Slide 26
Physical Assessment
Focussed Examination
Inspection
Palpation
Percussion
Auscultation
§ Contemplation
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Slide 27
Physical Assessment
Focussed Examination (cont)
Inspection
§ Chest wall
§ Breathing patterns
§ Pink puffers & blue bloaters
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Slide 28
Physical Assessment
Inspection of the Chest
Surface markings
Shape
Breathing pattern
Movement
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Slide 29
Physical Assessment
Focussed Examination (cont)
Palpation
§ Trachea & mediastinum
§ Chest wall
Systematic approach
§ Comparison made with both sides of body
§ Start from front – apex of lung & work down
¥ Lateral sides & axilla
§ Sit patient forward – examine back
§ Vocal fremitus
§ Chest expansion
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Slide 30
Physical Assessment
Palpation
Mediastinal position
Chest expansion
Tactile vocal fremitus
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Slide 31
Physical Assessment
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Slide 32
Physical Assessment
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Slide 33
Physical Assessment
Focussed Examination (cont)
Percussion
§ Detect resonance or hollowness of chest
§ Technique
¥ Bell clapper
¥ Compare each side
¥ Finger on chest parallel with expected line of dullness
¥ Placed over IC space
¤ Apex of lung = mid clavicle
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Slide 34
Physical Assessment
Percussion
Technique
Findings
§ Resonant
§ Dullness
§ Stoney dullness
§ Hyper-resonant
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Slide 35
Physical Assessment
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Slide 36
Physical Assessment
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Slide 37
Physical Assessment
Focussed Examination (cont)
Auscultation
§ Correct use of stethoscope
§ Technique
¥ Start at apices, work down, comparing each side
§ Report on:
¥ Breath sounds¤ Vesicular or Bronchial
¥ Added sounds¤ Crackles (crepitations/rales), wheezes (rhonchi), stridor and rubs
§ Vocal resonance
¥ Whispering pectoriloquy
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Slide 38
Physical Assessment
Auscultation
Technique
Findings
§ Vesicular
§ Reduced
§ Bronchial
¥ Added sounds
¤ Wheeze
¤ Crackles
¤ Rub
§ Vocal resonance
¥ Whispering
pectoriloquy
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Slide 39
Physical Assessment
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Slide 40
Physical Assessment
Breath Sounds
Vesicular§ Heard over normal lungs
¥ Rustling quality
¥ Heard on inspiration and first part of expiration
Bronchial§ Difficult to describe
¥ Described by its timing
Added sounds§ Crackles (rhonchi)
§ Wheezes (rales; crepitations)
§ Rubs
Vocal resonance§ 99
¥ Fuzzy sound
¥ Whispering pectoriloquy
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Slide 41
Physical Assessment
Respiratory Investigations
Sputum examination
CXR - chest radiograph
Pulmonary function
§ PEFR - maximum flow rate
§ FEV1 - forced expiratory volume
§ FEV1/VC - measure of resp. function
Bronchoscopy
VQ scan - ventilation/perfusion mismatch
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Slide 42
Physical Assessment
Lung Function Tests
PEFR
FVC
FEV1
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Slide 43
Physical Assessment
Assessing Lung Function
Static Lung volumes
§ Total Lung Capacity (TLC)
§ Vital capacity (VC)
§ Tidal Volume (TV)
§ Residual Volume & Forced Residual Volume
Dynamic lung volumes
§ Spirometry
§ VC; FEV1;FEV1%
Peak flow
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Slide 44
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Slide 45
Physical Assessment
Peak Expiratory Flow Rate
Flow generated by first 0.1s of a forced
expiration
§ Figure is extrapolated over 1 min
§ Normal ratio dependant on age & sex
Serial recording useful in diagnosis &
management of asthma
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Slide 46
Physical Assessment
Forced Vital Capacity
Measured by spirometric trace
§ Forced exhalation from total lung capacity (TLC) to
residual volume (RV)
§ Amount exhaled forcefully from a single deep
inspiration
FEV1 is fraction of that volume in first one
second
§ Expressed as ratio FEV1/FVC (FEV1%)
¥ Normally 75%
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Slide 47
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Slide 48
Physical Assessment
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Slide 49
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Slide 50
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Slide 51
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Slide 52
Physical Assessment
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Slide 53
Physical Assessment
Severity
COPD diagnosed if:
§ FEV1 <80% predicted
§ FEV1/FVC <70%
Severity is measured
using FEV1:
§ <80% = mild
§ <60% = moderate
§ <40% = severe
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Slide 54
Physical Assessment
Framework for respiratory
examinationWhilst taking history note any respiratory distress
Look at hands for clubbing, cyanosis
Mucous membrane for central cyanosis
Check JVP
Inspect chest wall
§ Deformities and inequalities
Pattern of breathing
Palpate trachea for displacement
Assess expansion of chest from front
Palpate for vocal fremitus
Percuss front of chest
Auscultate chest and decide on nature and presence of breath sounds
Test for vocal resonance and ‘whispering pectoriloquy’
Note added sounds
Repeat for back
PFR
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