Examination of Respiratory System

Examination

The assessment procedure discussed below is commonly performed by a physical therapist during the examination of a patient with primary or secondary pulmonary dysfunction.

Aim of the Examination

• Determine a patient's primary and secondary respiratory and ventilatory impairment how they limit physical function.
• Determine the adequacy of the ventilatory pump.
• Discover a patient's suitability for participation in a pulmonary rehabilitation program.
• Develop an appropriate intervention plan for the patient.
• Establish baseline information to measure a patient's progress and the effectiveness of the treatment.
• Plan and implement a home care program.

History

The examination process begins with the patient's history including an interview with the patient and family members. During the interview, the therapist can identify the patient's and family member's perception of any functional limitations for disabilities and determine the patient's chief complaints. The medical history and any medical diagnosis are obtained from the patient's medical record. Relevant occupation and social history are obtained.

Observation

1. General Appearance of the patient

1. Level of Consciousness

• Implication- respiratory acidosis, hypercarbia (increased partial  Pco2 level), hypoxia (decreased Po2 level) can alter the level of consciousness.

2. Body type: Normal, thin, obese

• Implication- may reflect intolerance to exercise.

3. Cyanosis: Peripheral, Central

• Implication- Peripheral cyanosis may indicate low cardiac output & Central cyanosis may indicate inadequate gas exchange in the lungs.

4. Hypertrophy or use of accessory muscles of ventilation

• Implication- seen in patients with early chronic lung disease or weakness of the diaphragm.

5. Supraclavicular or intercostal retractions occurring with inspiration

• Implication- seen in patients with labored breathing.

6. Use of pursed-lip breathing

• Implication- indicate difficulty with expiration and seen in patients with COPD.

7. Clubbing: loss of angle between the nail bed and the DIP joint.

• Implication- link to increase perfusion.

8. Peripheral Edema

• Implication- the sign of right ventricular failure or lymphatic dysfunction.

2. Analysis of chest

1. Chest Dimensions
2. Common chest deformities
3. Breathing pattern
4. The symmetry of chest movement

Chest Dimensions:

The AP and lateral dimensions are usually 1:2.

Common chest deformities:

• Barrel Chest: the circumference of the upper chest appears larger than the lower chest. The patient with COPD, who are usually upper chest breathers, develop a barrel chest.
• Pectus excavatum (funnel chest): the lower part of the sternum is depressed and the lower ribs flare out. Patients with these deformities are diaphragmatic breathers.
• Pectus carinatum (pigeon chest): the sternum is prominent and produits anteriorly.

Breathing pattern: 

• Assess the rate of regularity and location of ventilation with rest and with activity.
• A normal respiratory rate is 12 to 20 beats per minute.
• The normal ratio of inspiration to expiration is at rest is 1:2 and with activity, is 1:1.

Abnormal breathing pattern

• Dyspnea: distressed, labored breathing as a result of shortness of breath.
• Tachypnea: rapid, shallow breathing. decrease tidal volume but increase rate. associated with and restrictive or obstructive lung disease and use of accessory muscles of respiration.
• Bradypnea: slow rate with shallow or normal depth and regular rhythm. It may be associated with a drug overdose.
• Hyperventilation: deep, rapid respiration with a regular rhythm. Increased tidal volume and increased rate of respiration.
• Orthopnea: difficulty breathing in the supine position.
• Apnea: Cessation of breathing in the expiratory phase.
• Apneusis: Cessation of breathing in the inspiratory phase.
• Cheyne-stokes: cycles of gradually increasing tidal volume followed by a series of gradually decreasing tidal volumes and then a period of apnea. This is sometimes seen in patients with a severe head injury.

Symmetry of chest movement:

The symmetry of chest movement during breathing indicates the mobility of the chest and what area of the lungs may or may not be responding.

• Procedure: place your hands on the patient's chest and assess the excursion of each side of the chest during inspiration and expiration.

Palpation

Palpation thorax can provide evidence of this function of underlying tissues including lung, chest wall, and mediastinum.

Tactile (vocal) fremitus:

This is the vibration felt as the therapist palpates over the chest wall as the patient speaks.

• Procedure:
• Place the palm of your hand lightly on the chest wall and ask the patient to speak a few words or repeat "99" several times.
• Normally, fremitus is felt uniformly on the chest wall.
• Fremitus is increased in the presence of secretion in the air-ways and decreased or absent when there is trapped as a result of obstructed airways such as in case of pneumothorax or pleural effusion.

Chest wall pain

Specific areas of pain over the anterior, posterior, or lateral aspect of the chest wall can be identified with palpation.

Mediastinal shift

• The position of the trachea is normally oriented centrally in relation to the suprasternal notch indicating symmetry of the mediastinum.
• The position of trachea shaped as the result of asymmetrical intrathoracic pressure for lung volumes.
• Procedure:
• To identify a mediastinal Shift, have the patient sit facing you with the head in midline and the neck slightly flexed to relax the sternocleidomastoid muscles. With your index fingers gently palpate the soft tissue space on either side of the trachea at the suprasternal notch. Determine whether the trachea is palpable at the midline or has shifted to the right or left.

Percussion

• This is an examination technique designed to assess lung density.
• Procedure:
• place the middle finger of the non-dominant hand flat against the chest wall along with an intercostal space. With the tip of the middle finger of the opposite hand tab formally on the finger position on the chest wall. repeat the procedure at several points on the right and left and anterior and posterior aspects of the chest wall. This manual produces a resonance; the pitch varies with the density of underlying tissue. 

The subjective determination of pitch indicates the following:

• The sound will be dull and flat if there is a greater than normal amount of solid matter (tumor, consolidation) in the lung in comparison with the amount of air.

• The sound will be hyper-resonant (tympanic) if there is a greater than normal amount of air in the area (as in patients with emphysema).

• If Asymmetrical or abnormal findings are noted then the patient should be referred to a physician.

Auscultation 

• Breath sounds occur because of the movement of air in the airways during inspiration and expiration.
• A stethoscope is used to magnify these breath sounds.
• Breath sounds should be assisted to:
• Identify the area of the lungs in which congestion exists.
• Identify the area of the lungs in which airway clearance technique should be performed.
• Determine the effectiveness of any airway clearance intervention.
• Determine whether or not the lungs are clear and whether or not interventions should be discontinued.

• Procedure: 
• When assessing breath sound be sure that the patient is comfortable, relaxed, sitting position. 
• Place the diaphragm of the stethoscope directly against the patient's skin along the anterior or posterior chest wall. 
• Be sure that the tubing does not rub together or come in contact with clothing during auscultation, as this contact produces extra sounds. 
• Follow a systematic pattern and place the stethoscope against specific thoracic in landmarks (T-2, T-6, T-10) along the right and left side of the chest wall.
• Ask the patient to breathe in deeply and out quickly through the mouth as you move the stethoscope from point to point.
• Note the quality, intensity, and pitch of the breath sounds.

Examination of Cough

• The strength, depth, length, and frequency of a patient's cough must be assessed.

• An effective cough is sharp and deep.

• In a patient with pulmonary dysfunction, a cough can be described as weak, shallow, soft, or throaty, which may result due to pain and paralysis.

• If a cough is weak and ineffective, suctioning may be required to clear the airways.

• A cough may be productive or non-productive in presence of pathology.

Examination of Sputum

Sputum should be checked for:

• Colour (clear, yellow, green, blood-stained)

• Consistency (viscous, thin, frothy)

• Amount (minimal or copious)

• Odor (no odor to foul smelling)

When secretions are produced during the course of interventions such as exercise for airway clearance, it is the responsibility of the therapist to document the characteristics of the secretions.

Table: Lung secretions and their associated disease
Lung secretion	Diseases
A small amount of clear or white secretion	Normal
Copious but clear secretion	Chronic Bronchitis
Yellow, green, purulent secretion with a foul odor	Lung Infections
Blood streaked secretion	Hemoptysis
Frothy, white secretion	Pulmonary edema and Heart failure

Examination of Muscle Strength

• Patients with pulmonary disease may have peripheral and ventilatory weakness due to deconditioning, malnutrition, steroid use, and systematic systemic effects of the disease process.

• Muscle weakness can contribute to exercise limitation and inability to perform activities of daily living.

• Measurement of muscle strength is done by Manual muscle testing (MMT).

• Measurement of muscle strength should be performed to determine the need for strength training during pulmonary rehabilitation.

Special Tests

• Radiology 

• Pulmonary function test (PFT)

• Exercise tolerance test (ETT)

• Functional performance measures 

• Atrial blood gas (ABG) analysis 

• Atrial oxygen saturation measurement

• Electrocardiograms (ECGs).

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