Next up, we're going to do the respiratory exam.
And like examination of many
systems, it starts with inspection.
So, I don't know about you, but I've
taken care of a number of patients,
who tell me that they're unable to breathe
and having significant respiratory distress
and they can go into great detail about that,
without even taking a breath.
In reality, a person who is legitimately
having respiratory distress,
should typically have a problem,
where they can't say more
than a few words at a time.
So, just looking at our patient right now,
he looks comfortable and if I asked
him to tell me how he was feeling,
as long as he can get out a few
words, a full sentence, etc.,
then I know that he's not in
significant respiratory distress.
It's worth documenting that on your physical exam,
your patient can speak, in only
one word or three-word sentences,
to really get at that picture very quickly.
In addition, patients who are in
respiratory distress, oftentimes,
use accessory muscles of respiration.
So, remember that, normally
if you're just breathing,
standard tidal volumes at rest,
you only need one muscle to do that
and that's your diaphragm.
So, just looking at our
patient relaxing right now,
taking normal tidal breaths
of inhalation and exhalation,
the only muscle that's working, is his diaphragm,
which right now is up, now it's going down,
then it goes up, it's going
down to draw air into his chest,
and then it relaxes.
And it's actually for inhalation,
that's the only time the
diaphragm is doing anything,
during exhalation, it's simply
the elastic recoil of the ribcage,
that is expelling air from your lungs.
In contrast, a person who's
in respiratory distress,
is going to use extra muscle groups to
help with both inhalation and exhalation.
So, let's first look at the muscles of inhalation,
the accessory muscles, of inhalation.
So, what I'm going to have you do Sean, is,
I want you to take a full deep
breath, as big as you can,
You'll note, you can see right here what happened,
his sternocleidomastoids and
his scalene muscles pulled up
his clavicles as well as his first rib
and by doing so, he's increasing the
amount of space in his chest cavity,
so, he can accommodate more air coming in.
So, that's one of the first signs that you'll see,
for inhalation in terms of accessory muscle use.
And now what I’m going to have you do Sean, is,
completely exhale completely
empty your chest of air.
Great. So, you can see right here he's
contracting his abdominal muscles,
because by contracting his abdominal muscles,
he is squeezing his abdominal cavity,
which pushes the diaphragm upwards and allows,
extra ability to expel air from the lungs.
In addition, you may have noticed a
subtle change where he leaned forward,
just a little bit.
What that was, was his intercostal
muscles of his rib cage also contracting,
which basically, just closes the cage to again,
assist with expelling air from the lungs.
Other findings that particularly you might
see in a person with a COPD exacerbation,
is, "Pursed lipped breathing."
When patients have emphysema,
there's a loss of the architecture that
supports the patency of small airways.
So, when they're trying to expel air,
the airways are collapsing, when
you do pursed lip breathing,
just basically push your
lips and try and breathe out.
With pursed lip breathing,
he's creating a back pressure,
so-called, “Positive End Expiratory
Pressure” that basically tense open,
those smaller airways to allow that
air to get out more effectively,
in the setting of emphysema.
The next thing that you might
see in a patient with emphysema,
is the tripoding position.
So, this is known as the tripoding position
and the patient is essentially using his arms,
to prop up his upper thorax,
which allows him to still
keep that ribcage very open,
but reduces the work of the accessory
muscles of respiration in the process.
So, this is another thing that you may find
in patients who particularly have emphysema,
who are in respiratory distress.
And perhaps the last and perhaps
most significant finding,
that you'll see in a person who is
legitimately in respiratory distress,
is, “Cyanosis” and we know this from
literature and movies and everything else,
that the patients get blue lips
and this is a very real finding,
with really exceptional likelihood ratios as well.
So, for a person who has an oxygen
saturation of less than 80%.
So, we'd be looking at his oxygen
saturation to tell us what his O2 sat is,
but even before we have an O2 sat monitor,
I'm just going to basically
take a look at his lips.
In a patient with cyanosis, they should
have a clear bluish discoloration
and Sean, can you open your mouth for me,
the tongue, would also be somewhat bluish in color
and lifting up your tongue,
underneath those mucous membranes,
beneath the tongue is where
you're most likely to see,
evidence of this bluish discoloration,
that is evidence of deoxyhemoglobinemia.