Clinical Examination of the Respiratory system

1. Clinical Examination of the Respiratory system Dr. Jim Storer

2. Anything Interesting? Seen any interesting patients in past week? Why were they interesting?

3. Areas to Cover Anatomy and Physiology Typical History Physical Examination Relevant Investigations Management COPD Summary

4. History Past History/ Length of History Nasal/ Pharyngo/ laryngeal symptoms Cough � sputum texture/ colour Haemoptysis � always important Shortness of Breath Pain Cyanosis � central / peripheral Night Sweats, weight loss, debility

5. Physical Examination General Inspection:- Respiratory distress, dyspnoea, tachypnoea, use of accessory muscles, wheeze or stridor Pattern of respiration, air hunger, Cheyne Stokes, Seesaw resp. Cyanosis, puffy face, vein engorgement, nasal flaring, fingers (nicotine, coal dust, clubbing) Hoarse voice, Horner�s syndrome Centrality of Trachea

6. Examination (cont) Palpation:- Lymphadenopathy, trachea, chest expansion, vocal fremitus Percussion:- Increased in Emphysema, pneumothorax � Decreased in consolidation, collapse, abscess, neoplasm, fibrosis � Stony dull with effusion

7. Examination (cont) Auscultation:- Cough up sputum, use diaphragm of stethoscope, breathe through mouth Normal breath sounds are not continuous, crepitations � fine and coarse, wheeze

8. Investigations Peak Flow Rate � max airflow expiration Spirometry � Vital Capacity, Forced VC, FEV1, FEV1/FVC x 100 % Oxygen saturation < 85% - cyanosis Sputum culture/ microscopy

9. Investigation (cont) CXR CT/MRI scan Endoscopy Biopsy

10. Management Depends upon diagnosis Oral medicines � antibiotics/ analgesics/ anticoagulants, steroids, leukotriene antagonist, B2-agonist, xanthines. Inhaled medicines � B2-agonists, anti-cholinergics/ muscarinics, steroids - long and short acting Oxygen

11. Management 2 Mucolytics � carbocysteine, steam Aromatic inhalations � menthol etc. Gough suppressants � codeine, morphine etc. Expectorants � simple linctus Nasal decongestants � pseudoephedrine

12. Chronic Obstructive Airways Disease 4 stages dependent on FEV1, FEV1/FVC. FEV1 <30% is v severe 60/1000 men > 65yrs, less for females Multiple aetiology � smoking, age, environmental pollutants, infections etc. Fibrosis and stenosis of small airways, mucous not so important

13. COPD (cont) Clinical features - cough and wheeze, exacerbations with purulent sputum, SOB on exercise, weather affect Wt loss, accessory muscle use, intercostal indrawing, poor chest expansion, hyper inflation, PP - BB Investigations � Lung FTs, pulse oximetry, CXR, FBC, BMI � CT thorax, ECG, cardiac echo, blood gases

14. COPD (cont) Management with inhaled SA & LA B2-agonists +/- inhaled steroids. Oral steroids >30mgm/day for short periods only. Antibiotics (rescue pack) +/- oxygen Complications � Respiratory failure, Cor pulmonale, Ca bronchus, wt loss, pneumothorax, polycythaemia.

15. COPD (cont) Prognosis is of slow deterioration 10%/ yr mortality rate once FEV1 is down to 1 litre With Cor Pulmonale � 5yr survival is 30%

16. Summary Respiratory problems are common A good history is, as always, essential Physical examination is enhanced by other procedures When marked cause severe anxiety as a result of C02 retention Any Questions