1
Q
What are some respiratory red flags?
A
- Cyanosis- indicates pt is hypoxic
- Tripoding, accessory muscle usage
- Nasal flaring/ head bopping- in paeds mainly
- Sternal/ intercostal recession
- Inability to complete full sentence
- Confused/ combative- brain is not being perfused, decreasing GCS
- Tachycardia/bradycardia
- Loss of wheeze without indication of improvement/ silent chest
- Tracheal tug
2
Q
What are the main respiratory PC?
A
- SOB/Dyspnoea and wheeze
- Cough/sputum
- Haemoptysis
- Chest pain
- Daytime sleepiness, snoring, disordered sleep
- Utilise SOCRATES
3
Q
SOB
A
- Is it cardiac or pulmonary?
- Is it on rest or exertion?
- How much exertion?- is this normal for pt?
- How many flights of stairs can they climb before pausing?- could they do this normally?
- Timing- commonly occurs in the morning for COPD pts. Coughing a lot at night could be HF
- Does positioning relieve it?
4
Q
Cough, sputum & haemoptysis
A
HX of cough:
- Dry, hacking cough- viral infection
- Chronic, productive cough- COPD, TB, pneumonia
- Wheezing- asthma, COPD, anaphylaxis, HF
- Barking- epiglottis, croup
*Acute<3 weeks- common cause of acute cough is URTI, Bronchitis, Pneumonia, L HF, asthma.
*Subacute: 3-weeks- Asthma, sinusitis, reflux
*Chronic>8weeks- Asthma, postnasal drip, bronchitis
5
Q
Obstructive sleep apnoea
A
- If pt complains of tiredness, sleepiness, ask about snoring!
- Do they wake up with a morning headache
- This is a respiratory issue where they stop breathing in the middle of the night and wake up gasping for air.
6
Q
ROS
A
- Appetite- reduced when unwell which could mean they are not getting enough nutrition, making them further unwell.
- Significant weight loss may indicate malignancy!
- Upper gastrointestinal symptoms- is it reflux?- does it taste metallic, does it occur a few hrs after eating? Burning sensation?
- Severe anaemia may cause breathlessness!
- Reffered pain- pt may have been coughing from a viral illness for the past few days and may now be experiencing pain from coughing excessively. Costochondritis
7
Q
Medications with respiratory side effects:
A
- Beta blockers & NSAIDS cause bronchoconstriction
- ACE inhibitors produce a dry cough (lisinopril, Ramipril)
- Oestrogen containing meds increase the risk of PE
- Amiodorane- pleural efffusion
- Aspirin- may worsen haemoptysis
8
Q
Allergies & SHx
A
- Occupational HX- may have been a mine worker, working with asbestos
- Hobbies & pets ?
- Recent travel? >4hrs think DVT
- Smoker/vaper?
Lifestyle & alcohol consumption, illicit drugs? - Sexual hx- HRT in pregnancy may cause thrombotic conditions!
- Are they fully immunised?- TB, COVID, Pneumonia, Influenza, Pertussis
9
Q
End of bed assessment
A
- Cyanosis/Pallor
- WOB
-Positioning/ tripoding - Scars
- Pain/distress?
- Cachexia- muscle wastage/very skinny - driven by chronic inflammatory response. Progress loss of skeletal muscle- typically in cancer pts or with chronic illnesses!
10
Q
What are you looking for in pts hands?
A
- Clubbing: low o2, may be a sign of HF, lung abscess, CF
- Peripheral cyanosis
- Nicoteine staining
- Delayed cap refill
- JACCOL
11
Q
PULSE CHECK
A
- Lung CA may lead to af- CHECK PULSE
- large/tension pneumothorax can cause pulsus paradox
12
Q
Asterixis-tremors
A
- Build up of toxic metabolites in the system, including co2 retention.
- Ask pt to extend their arms & observe the hands for 20-30secs- tremors indicate high dose bronchodilator drugs!
- Ask pt to bend their wrists back to 90 with fingers open for 20-30 seconds.- A flapping tremor may occur, indicating possible CO2 retention.
13
Q
Mouth
A
- Ensure to look inside pts mouth!
- Look around mouth
- Angular stomata- sores around the mouth, may be B12 deficiency
- Does the tounge look dry?- May indicate mouth breathing!
- Any nasal flaring, pursed lip breathing?
- Oral candidiasis- fungal infection. Usually secondary to immune suppression but can be associated with steroid inhaler use!
14
Q
Raised JVP:
A
Causes:
- RHF
- Cor pulmanale
- Arrhythmia
- PE
- Pneumothorax
15
Q
Lymph nodes
A
- Make sure you learn the names and how to palpate for them
- Are they enlarged?
- Supraclavicular- if that’s enlarged, it may be a sign of abdominal cancer!
16
Q
Inspecting the chest:
A
- Be systematic! Start from the front, then move to the back
- Look for: SWEADES, Chest shape,
General observation: - Resp rate- is it appropriate for age?
- Any additional sounds?- Cough, wheeze, absent
- Cachexia?
- Accessory muscle usage
- Any pacemakers, ICD, CABG scar
- Any kyphosis- as long as causing long term back ache, it can cause DIB due to compression of heart and lungs
- Pigeon chest, any defects in the sternum?
- Barrel chest- What’s the anterior posterior ratio?- The width of their chest should be bigger than the depth of their chest!
17
Q
What is kusmaul breathing?
A
- Fast and deep breathing, indicates metabolic acidosis, often seen in DKA
18
Q
What is cheynestrokes respiration?
A
- Irregular breathing with intermittent periods of increased and decreased rates of breaths with periods of apnoea
- May be drug induced
19
Q
Don’t forget the legs
A
- Peripheral oedema- lower legs & sacrum
- DVT
20
Q
PALPATION
A
- identify tender areas
Chest expansion; - Is it symmetrical?
- Look anteriorly and posteriorly!- place hands over chest wall and place thumbs on xiphoid and get pt to inhale first and exhale slowly
21
Q
Tactile fremitus
A
- Sound vibration produced in the larynx during phonation are transmitted to the bronchi and lungs which are communicated to the chest wall.
Tactile fremitus= palpation of these vibrations on the chest wall as pt speaks. - Get pt to say 99, place ulna aspects (pinky finger) of hand bilaterally on the back of pts chest.
- Palpate twice anterior and posterior
WHAT IT MEANS:
- In healthy lungs, vibrations are barely palpable
- When tissue is consolidated (full of fluids/ mucus/debris), the vibrations increase
22
Q
Percussion
A
- Produces a sound of vibration under underlying tissue.
- Increased resonance indicates increased AIR trapped in the lungs/ pleural space.
- Decreased resonance indicates FLUID in the pleural space or consolidation (pus/exudate) of the lungs.
- Dull sounds will be heard around the 3rd/4th rib on the left sternal border due to the heart!!
23
Q
Percussion sounds
A
— Normal resonance- low pitched, hollow
— Hyper resonance- Louder, low pitched
— Hypo-resonance- dull/ thud like , high pitched sound- Fluid filled
24
Q
Auscultation
A
- Sound is produced by air movement through the bronchi
- Crackles often heard at the basis
25
What are normal breath sounds called?
- Vesicular, gentle & quiet, no gap between inspiratory and expiratory.
- Bronchial- heard over the trachea- loud, harsh, high pitched
26
Crackles
- Rales, intermittent, usually on inhalation
- Crackles heard at the bases of the lungs are likely to be due to pulmonary oedema
- Stridor- harsh inspiratory sound, caused by partial obstruction in the airway.
- Pleural rub- creaking sound
27
Vocal fremitus
- Listening for vibration without stethoscope
- Increased transmitted voice sounds, think exudate and fluid in their lungs- think Pnemonial pleural effusion.
- If it’s heard louder, the airway is blocked by inflammation/secretion
28
Bronchophony
- Get pt to say 99, it should be muffled.
- HOWEVER, if heard over areas of consolidation, it will sound loud and clear.
- IF, you have a pt with a productive cough, malaise, fatigue with a temp and you suspect pneumonia, perform this.
29
Egophony
- Get pt to say EEEE, it should sound muffled.
- HOWEVER, if heard over areas of consolidation, the sound should be heard as AAAAA
30
Whispered pectoriloquy
- Get pt to whisper 123, you should not hear them through stethoscope!
- Over consolidation, it should be loud & clear!!
31
Difference between hospital & community acquired pneumonia:
- Hospital acquired pneumonia is classified as a respiratory tract infection, develops 48hrs after admission!- This bacteria is often resistant to antibiotics
- Community is often not resistant to antibiotics
PMMH
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