pulmonary disorders
Evaluation of the Pulmonary Patient
Physical Examination
Physical examination includes an assessment of general appearance. Discomfort and anxiety, body habitus, and the effect of talking or movement on symptoms (eg, inability to speak full sentences without pausing to breathe) all can be assessed while greeting the patient and taking a history and may provide useful information relevant to pulmonary status. A thorough pulmonary examination constitutes inspection, auscultation, and chest percussion and palpation. Patients with lung disease should undergo a complete physical examination, including examination of lymph nodes, skin, and the musculoskeletal system. Inspection should focus on Signs of respiratory difficulty and hypoxemia (eg, restlessness, tachypnea, cyanosis, accessory muscle use) Signs of possible chronic pulmonary disease (eg, clubbing, pedal edema) Chest wall deformities Abnormal breathing patterns (eg, prolonged expiratory time, Cheyne-Stokes respiration, Kussmaul respirations) Jugular venous distention A sign of hypoxemiais cyanosis (bluish discoloration of the lips, face, or nail beds), which requires the presence of at least 5 g/dL of unsaturated hemoglobin and thus signifies low arterial oxygen saturation (<85%); the absence of cyanosis does not exclude the presence of hypoxemia. include tachypnea, use of accessory respiratory muscles (sternocleidomastoids, intercostals, scalenes) to breathe, intercostal retractions, and paradoxical breathing. Patients with Chronic Obstructive Pulmonary Disease (COPD) sometimes brace their arms against their legs or the examination table while seated (ie, tripod position) in a subconscious effort to provide more leverage to accessory muscles and thereby enhance respiration. Intercostal retractions (inward movement of the rib interspaces) are common among infants and older patients with severe airflow limitation. Paradoxical breathing (inward motion of the abdomen during inspiration) signifies respiratory muscle fatigue or weakness. Signs of possible chronic pulmonary diseaseinclude clubbing, barrel chest (the increased anterior-posterior diameter of the chest present in some patients with emphysema), and pursed lip breathing. 1—see figure Measuring finger clubbing ). “Sponginess” of the nail bed beneath the cuticle also suggests clubbing. Clubbing is most commonly observed in patients with Lung Carcinoma but is an important sign of chronic pulmonary disease, such as The ratio of the anteroposterior diameter of the finger at the nail bed (a–b) to that at the distal interphalangeal joint (c–d) is a simple measurement of finger clubbing. It can be obtained readily and reproducibly with calipers. If the ratio is>1, clubbing is present. Finger clubbing is also characterized by loss of the normal angle at the nail bed. Barrel chestis the increased anterior-posterior diameter of the chest present in some patients with emphysema. Inpursed lip breathing, the person exhales through tightly closed lips and inhales through the nose with the mouth closed. This maneuver increases pressure in the airways to keep them open and thereby decrease gas trapping. Chest wall deformities,such as pectus excavatum (a sternal depression usually beginning over the midportion of the manubrium and progressing inward through the xiphoid process) and kyphoscoliosis, may restrict respirations and exacerbate symptoms of preexisting pulmonary disease. These abnormalities can usually be observed during careful examination after the patient's shirt is removed. Inspection should also include an assessment of the abdomen and the extent of obesity, ascites, or other conditions that could affect abdominal compliance. Abnormal breathing patternsmay suggest underlying disease processes. A prolonged expiratory to inspiratory ratio occurs in obstructive lung disease. Some abnormal breathing patterns cause fluctuations in respiratory rate so respiratory rate should be assessed and counted for 1 minute. (periodic breathing) is a cyclic fluctuation of respiratory rate and depth. From periods of brief apnea, patients breathe progressively faster and deeper (hyperpnea), then slower and shallower until they become apneic and repeat the cycle. Cheyne-Stokes respiration is most often caused by Heart Failure (HF) , a neurologic disorder (eg, is an uncommon variant of Cheyne-Stokes respiration in which irregular periods of apnea alternate with periods in which 4 or 5 deep, equal breaths are taken. It differs from Cheyne-Stokes respiration in that it is characterized by abrupt starts and stops and lacks periodicity. It results from injury to the central nervous system and occurs in such disorders as Overview of Meningitis . are deep, regular respirations caused by Metabolic Acidosis . Neck veins None Lung auscultation is arguably the most important component of the physical examination. All fields of the chest should be listened to, including the flanks and the anterior chest, to detect abnormalities associated with each lobe of the lung. Features to listen for include Character and volume of breath sounds Presence or absence of vocal sounds Pleural friction rubs Cardiac Auscultation may reveal signs of are slightly louder, harsher, and higher pitched; they normally can be heard over the trachea and over areas of lung consolidation, such as occur with Overview of Pneumonia . Typical breath sounds heard over most lung fields. Audio file courtesy of David W. Cugell, MD. Typical breath sounds heard over the trachea and areas of lung consolidation. Audio file courtesy of David W. Cugell, MD. Audio file courtesy of David W. Cugell, MD. Prolonged expiratory phase with wheezing. Audio file courtesy of David W. Cugell, MD. Inspiratory stridor in croup. Audio file courtesy of David W. Cugell, MD. A leathery sound that fluctuates with the respiratory cycle. Audio file courtesy of David W. Cugell, MD. Areas of consolidation cause a patient's vocalized "E" to sound like "A." Audio file courtesy of David W. Cugell, MD. Adventitious sounds are abnormal sounds, such as crackles, rhonchi, wheezes, and stridor. (previously called rales) are discontinuous adventitious breath sounds. Fine crackles are short, high-pitched sounds; coarse crackles are longer-lasting, low-pitched sounds. Crackles have been compared to the sound of crinkling plastic wrap or the opening of Velcro (in Overview of Interstitial Lung Disease ) and can be simulated by rubbing strands of hair together between 2 fingers near one’s ear. They occur most commonly with are low-pitched respiratory sounds that can be heard during inspiration or expiration. They occur in various conditions, including Chronic Obstructive Pulmonary Disease (COPD) . The mechanism may relate to variations in obstruction as airways distend with inhalation and narrow with exhalation. Wheezesare whistling, musical breath sounds that are worse during expiration than inspiration and involve narrowing of small airways. Wheezing can be a physical finding or a symptom and is usually associated with dyspnea. Stridoris a high-pitched, predominantly inspiratory sound formed by extrathoracic upper airway obstruction. It usually can be heard without a stethoscope. Stridor is usually louder than wheezing, is predominantly inspiratory, and is heard loudly over the larynx. It should trigger a concern for life-threatening upper airway obstruction. signify poor air movement in airways, as occurs with Asthma and Vocal sounds are heard during auscultation while patients vocalize. occur when the patient’s spoken or whispered voice is clearly transmitted through the chest wall. Voice transmission results from alveolar consolidation, as occurs with Overview of Pneumonia . Egophony(E to A change) is said to occur when, during auscultation, a patient says the letter “E” and the examiner hears the letter “A,” again as occurs with pneumonia. are grating or creaking sounds that fluctuate with the respiratory cycle and sound like skin rubbing against wet leather. They are a sign of pleural inflammation and are heard in patients with Viral Pleuritis or empyema and after thoracotomy. 1:3 when airflow is limited, such as in Asthma and is the primary physical maneuver used to detect the presence and level of Pleural Effusion . Finding areas of dullness during percussion signifies underlying fluid or, less commonly, consolidation. includes tactile fremitus (vibration of the chest wall felt while a patient is speaking); it is decreased in pleural effusion and Pneumothorax and increased in pulmonary consolidation (eg, lobar pneumonias). Point tenderness on palpation may signal underlying A right ventricular impulse at the left lower sternal border may become evident and may be increased in amplitude and duration (right ventricular heave) in patients with Cor Pulmonale . 