Respiratory Assessment

Multiple resources available:

• Patient's notes (HPC, PMH, SH, investigations, risk factors)
• Charts (BP, HR, RR, SpO2, ABGs, peak flow, meds, temp)
• Subjective (symptoms, functional limitations)
• Observation (chest shape, colour, hands, oedema, breathing pattern, sputum)
• Palpation (abdomen, chest expansion, hydration, percussion)
• Ausculation (breath sounds, voice sounds, added sounds)
• Chest x-ray
• Exercise tolerance
• Equipment (O2, humidification, drips, drains, monitors)

Subjective Assessment

How long have their symptoms been troublesome?

What is their frequency and duration? Quality and severity?

Are they getting better or worse? Aggs and eases?

The four cardinal symptoms of chest disease are:

• Wheeze
• Pain
• Breathlessness
• Cough (+/- sputum)

Wheeze is caused by narrow airways and increases WOB. It is tightness in the chest on breathing out, not just noisy, laboured or rattly breathing. It is aggravated by exertion of allergies. Confirm objectively with auscultation.

Lung parenchyma contains no pain fibres, but chest pains relevant to physios are:

• Pleuritic pain - sharp, stabbing pain. Worse on deep breathing, coughing, hiccuping, talking and being handled. Causes include pleurisy, pneumonias, pneumothorax, rib fractures and pulmonary embolism.
• Musculoskeletal pain - e.g. from too much coughing or costovertebral tenderness due to hyperinflation
• Raw central chest pain - worse on coughing. Caused by tracheitis and associated with upper respiratory tract infection or excessive coughing.
• Angina pectoris - paroxysmal suffocating pain that is greater with exertion or stress, due to myocardial ischaemia. It is substernal or left anterior, sometimes radiating to the lest arm or jaw.

Breathlessness - how much are they able to do at their best? What are they unable to do now because of their breathing?

Cough is abnormal if it is persistent, painful or productive. It is caused by inflammation, irritation, habit or excess secretions. 

• What started the cough?
• Is it productive?
• What is the sputum like? Colour? Thickness?
• Has is changed in quality or quantity?
• Is there any blood?
• Is it painful?
• Does the cough occur at night? (This suggests gastro-oesophageal reflux or asthma)

Possible causes of cough include:

• Dry
• Asthma, ILD, recent viral infection, hyperventilation syndrome
• Productive
• Bronchiectasis, chest infection, COPD, CF
• Early morning
• COPD, postnasal drip
• With position change
• Asthma, GOR, bronchiectasis
• With exertion
• Asthma, ILD, COPD
• Inadequate
• Pain, weakness, poor understanding
• Paroxysmal
• Asthma, aspiration, upper airways obstruction

Objective Assessment

Pallor is associated with anaemia, reduced CO or hypovolaemic shock. Cyanosis is blue coloration due to unsaturated haemoglobin. Peripheral cyanosis shows at the fingers, toes and ear loves and signifies reduced circulation. Stagnant blood desaturates and gives a blue appearance. Causes include a cold environment or peripheral vascular disease. Central cyanosis shows at the mouth, lips and tip of the tongue and indicates a gas exchange problem.

Looking at the hands is surprisingly useful:

• Cold = reduced CO
• Warm = CO2 retention
• Asterixis (flapping tremor of outstretched hand that disappears when the hand is by the side) = CO2 retention
• Fine tremor = side effect of bronchodilators
• Nicotine stains = ex-smoker
• Clubbing (loss of angle between the nail and nail bed) = pulmonary (75%), cardiac (10%) or gut (10%)

Oedema = excess fluid in the interstitial spaces. Peripheral oedema accumulates at the ankles or sacral area depending on posture.

Chronic lung disease can lead to rigid, barrel-shaped, hyper inflated chest with horizontal ribs. Abnormalities of the chest wall such as kyphosis may lead to increased WOB.

Respiratory Rate

• Average = 10-20 breaths/minute.
• Tachypnoea = RR > 40 breaths/minute and leads to respiratory alkalosis and increased WOB due to turbulence
• RR < 8 breaths/minute --> increased PaCO2 --> respiratory acidosis

Laboured Breathing is shown by the following:

• Accessory muscle contraction
• Retraction of soft tissues of the chat wall on inspiration: supraclavicular, suprasternal and intercostal spaces
• Forced exhalation with active contraction of the abs which compresses the airways and increases WOB further (Ninane et al, 1992)
• Pursed lip breathing

Inspiratory muscle fatigue, weakness and overload are indicated by:

• Paradoxical breathing (use of abs)
• Rapid, shallow breathing
• Alternate movement of abs and rib cage to allow rest

Sputum is typically swallowed in small quantities in healthy individuals. Haemoptysis = sputum and blood. It is bright red when fresh, pink if mixed with sputum or rusty brown if it's old. 

• Raw egg white = COPD or cancer
• Yellow/green = infection or bronchiectasis
• Thick plugs = asthma
• Frothy = pulmonary oedema

Auscultation

Sounds at Mouth

• Noisy breathing = increased turbulence due to obstructed upper airways manifested as crackles or wheeze
• Crackles heard at the mouth should be cleared with a cough to prevent transmitted sounds
• The squeak = stridor = monophonic wheeze. This is a serious sign that denotes laryngeal or tracheal contraction to a diameter as small as 5mm. Suction should be avoided and the patients head elevated to minimise oedema

Lung Markings

• UL = 2.5cm above clavicle
• Horizontal fissure = 4th rib
• Oblique fissure = 6th rib
• Posteriorly oblique fissure = T3
• UL = T1
• LL = T10

Normal Breath Sounds

• Tracheal = loud and high pitched
• Vesicular = over lung = soft and low
• Bronchial = loud and high pitched
• Bronchovesicular = intermittent

Bronchial breathing in unusual areas indicates consolidation, as does bronchovesicular such as pneumonia or atelectasis

Reduced breath sounds = reduced air flow, obstruction in the airway or increased distance

Added Sounds

Crackles - high pitch, discontinuous, more common on inspiration.

          Fine = high pitched, soft, brief with breath sounds

          Coarse = low pitched, loud, less brief with less breath sounds

          Late inspiratory = opening peripheral airways

          Early inspiratory = reopening large airways

          Late expiratory = clear secretions in peripheral airways

          Early expiratory = clear secretion in large airways

Wheeze - high pitch, continuous, hissing

          High pitch = bronchospasm

          Low pitch = sputum

          Localised = tumour or foreign body

Pleural Rub - creaking and rubbing

          Inflammation of pleura, infection, tumour

Voice Sounds

Tactile vocal fremitus = bronchial breathing when vibrations of words can be felt by hands (note, this isn't normal)

Aegophony = voice sounds through air on top of pleural effusion

Percussion

Flat or dull - pleural effusion or local pneumonia (e.g. over thigh)

Hyper resonant = emphysema or pneumothorax (e.g. over cheek)