Resp Exam Signs

Introduction

The respiratory examination, is an important skill to grasp. While it is technically straightforward, interpreting the results and understanding the jargon associated with the findings is also important, and unfortunately much more challenging.

The respiratory examination involves:

• Inspection
• Percussion
• Auscultation Sounds With thanks to Steve Kraman for making the following resource open source: https://www.mededportal.org/doi/10.15766/mep_2374-8265.129

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Inspection

• Tar staining – from chronic, high frequency smoking
• Finger Clubbing- Swelling as a result of ↓O₂
  • Causes can be remembered with an ABCDEF:
    • A-Asbestosis
    • B-Bronchiectasis
    • Cancer and CF
    • DON’T SAY COPD – not a cause but misconception it is
    • Empyema
    • Fibrosis – ILDs
• Fine tremor- Salbutamol use – since a sympathetic agonist of Beta receptors- long term use can cause systemic effects
• Flapping tremor- CO₂ retention
• Koilonychia in nails – Inward spooning – making a concave surface (Koilo- coming from the latin for hollow/concave)

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Percussion

• Normal note
• Dull Note – Consolidation, Tumour, Lobar collapse -Same as the sound from percussing the liver.
  • Still has a more resonant quality than stony dullness as there is still air within the consolidated alveoli- just not as much as there once was, hence the dullness.
• Stony Dullness– Pleural effusion -The sound of percussing the finger alone – the underlying area does not amplify this sound.
  • Underlying area does not amplify sound as a pleural effusion will ”block off” air deep to it from amplifying the sound.
• Hyper resonant note – Pneumothorax (on affected side)

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Auscultation

Normal sounds

From the alveoli – described as “vesicular”:

Tracheal:

Broncho-vesicular – somewhere in the middle between above (in location on respiratory tree and pitch):

NOTE- Crackles can be a NORMAL finding – it can been found in some when inspiring from the point of residual volume within the lungs when auscultating on the anterior chest.

To try this: expire all the way and breathe in slowly – holding the stethoscope in the 4th/5th intercostal space on the right (avoids heart sounds)

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Crackles

Crackles when breathing in deeply – and especially when heard on the posterior chest are ALWAYS abnormal.

Fine Crackles: -sound like Velcro, ONLY on Inspiration

• Suggestive of Congestive Heart failure, pulmonary fibrotic disease

Coarse Crackles – have a popping quality, usually only on inspiration but also expiration too – can be heard at the mouth and can be cleared with a cough.

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Bronchial Breathing

When auscultating the periphary of the lung- alveolar vesicular sounds should be heard.

If lower pitched, bronchial sounds are heard instead- this indicates airlessness in the underlying tissue.

This can be due to: consolidation or a collapsed lobe (ateletectasis)

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Wheeze and Stridor

Wheeze -disruption in flow to the lower airway- sound on EXPIRATION – think asthma

Stridor- disruption in flow to the upper airway – sound on INSPIRATION – think croup, cancer

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Misc

Pleural (friction) rub

Due to pleura becoming rough and catching (instead of being smooth and gliding over each other) – due to any inflammation of pleura.

-Occurs throughout BOTH inspiration and expiration

Death Rattle

Heard mostly in elderly. So termed as it is a sound that occurs in those unable to clear their own secretions due to the toll their illness has taken on them.

Rhonchi

Occur in expiration

“A bubbly, lower pitched wheeze”

-associated with chronic bronchitis, bronchiectasis