TLDR;
This video provides a comprehensive guide to performing a respiratory system examination. It covers key aspects such as history taking, inspection, palpation, percussion, and auscultation. The video also explains how to differentiate between various respiratory conditions like asthma, COPD, pleural effusion, pneumothorax, and lung tumours based on examination findings.
- General and focused history taking is crucial for identifying respiratory pathology.
- The four components of respiratory examination are inspection, palpation, percussion, and auscultation.
- Different respiratory conditions present with unique findings during each stage of the examination.
Introduction to Respiratory Examination [0:05]
The video introduces a respiratory system examination demonstration. It emphasises the importance of obtaining a detailed general history to identify potential respiratory issues. Patient consent is crucial before proceeding with the examination. Ideally, the examination should be performed with the patient undressed, but for comfort, the patient remains clothed in this demonstration.
General Inspection [0:38]
The general inspection involves observing the patient for signs like cyanosis (at the tip of the tongue and fingers) and clubbing of the fingertips. The examiner should also check for cervical and axillary lymphadenopathy, as these areas drain the lungs and pleura, respectively.
Inspection [1:11]
The initial step involves inspecting the trachea to ensure it is central. The symmetry of chest movements is assessed to identify any abnormalities. The examiner looks for skeletal deformities, scars, and the apical impulse, typically located in the left fifth intercostal space at the midclavicular line. These observations help determine if the mediastinum is shifted or if there are lesions affecting lung movement. The patient is turned to inspect the back for any drooping of the shoulders. The examiner also checks for intercostal indrawing, which can indicate breathing difficulties or lung volume loss. The activity of accessory muscles, such as intercostal muscles, is noted as increased activity suggests respiratory distress.
Sternum and Spine Inspection [3:03]
The sternum is inspected for abnormalities like Pectus excavatum (hollow sternum) and Pectus carinatum (bulged sternum), which can affect lung positioning. The spine is examined for kyphosis or scoliosis. Tenderness in the sternum, spine, or ribs is assessed, as it can indicate conditions like malignancy causing rib pain and breathlessness.
Palpation [4:06]
Palpation begins by checking for local temperature rises on the chest using the dorsum of the hand, followed by assessing for any bony tenderness. Tracheal position is confirmed by palpating the sternoclavicular joints and running a finger down to check for deviation. Respiratory movements are assessed by placing hands on the patient's back to observe upward and downward movements, as well as expansion. Anteriorly, hands are placed to observe the "bucket handle movement," where the chest expands upwards and outwards.
Lung Location and Diameter Measurement [5:59]
The location of lung lobes is clarified, noting that the front of the chest primarily corresponds to the upper lobes, while the back mainly corresponds to the lower lobes. The circumference of the chest is measured at the level of the nipples in the front and the T7 vertebra at the back to assess chest expansion during deep breaths, aiming for a minimum expansion of 2 cm. The video also explains how to measure the transverse and anteroposterior (AP) diameters of the chest using books or pads. Normally, the transverse diameter should be greater than the AP diameter. A reversed ratio, where the AP diameter is equal to or greater than the transverse diameter, is indicative of a barrel-shaped chest, commonly seen in COPD.
Percussion [8:56]
Percussion of the anterior chest wall involves systematically percussing areas such as the supraclavicular, clavicular, infraclavicular, mammary, and inframammary regions. The technique involves using the middle finger and wrist to create a percussion note. Liver dullness is identified around the sixth intercostal space, and the patient is asked to take a deep breath to see if the dullness shifts downwards. The axillary regions are percussed with the patient's arm raised. Posteriorly, percussion is performed in the supra-scapular, inter-scapular, and infra-scapular areas with the patient's hands placed appropriately. Different percussion notes are explained: resonance (normal lung), dullness (fluid or solid tissue), impaired resonance (partial consolidation), and stony dullness (pleural effusion).
Auscultation [13:03]
Auscultation begins by listening to the trachea to identify bronchial breath sounds, which are high-pitched with a gap between inspiration and prolonged expiration. Vesicular breath sounds are then auscultated in other areas, noting their lower pitch and the filtration effect of the lungs. The same areas percussed earlier are auscultated to identify any abnormalities. In pneumonia, bronchial breath sounds may be heard instead of vesicular sounds due to consolidation. Pleural effusion can reduce breath sounds, while fibrosis can cause crepitations. Tumours can also produce bronchial breath sounds unless the bronchus is obstructed, leading to absent breath sounds.
Vocal Fremitus and Resonance [16:03]
Vocal fremitus is assessed by placing hands on the patient's chest and asking them to say "one, one" to feel for vibrations. Vocal resonance is checked using a stethoscope while the patient repeats "one, one" to assess sound transmission. Increased vocal fremitus and resonance can indicate consolidation, while decreased fremitus and resonance suggest pleural effusion or pneumothorax.
Differentiating Respiratory Conditions [17:58]
The video outlines how to differentiate between asthma and COPD based on risk factors, age, disease progression, and pulmonary function tests. Asthma is characterised by intermittent symptoms, younger age of onset and reversibility with bronchodilators, whereas COPD is characterised by progressive symptoms, older age of onset and smoking history. Clinical findings for pleural effusion include tracheal deviation to the opposite side, reduced chest movements, stony dullness on percussion, and decreased vocal fremitus and resonance. Pneumothorax presents with tracheal deviation to the opposite side, reduced chest movements, hyper-resonance on percussion, and decreased vocal resonance and fremitus. Tumours can cause tracheal deviation to the same side and bronchial breath sounds on auscultation, while fibrosis can lead to crepitations.
