Lung Examination: Fixed Airways Obstruction – Lung Disease

by Jeremy Brown, PhD

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    00:00 that means the crackles themselves will be asymmetric in distribution.

    00:01 Smaller patches of consolidation, you’re not going to identify. Percussion note changes or much change in expansion of the chest when the patient breathes in and out. And really it’s the crackles that give the game away and identify the presence of consolidation in those circumstances.

    00:19 Now airways obstruction: COPD is a very common disease. And therefore we will see patients frequently with COPD. But one of the subtleties of that disease is that actually it’s quite hard to identify a patient with COPD when you listen to their chest with a stethoscope.

    00:41 And that, it’s the general observation of the chest which gives you more clues perhaps as to what’s going on. So the patient may be breathless. But that’s not specific for COPD, of course. They may be using accessory muscles of respiration. There may be excessive abdominal movement on inspiration. But again, that’s not specific for COPD. Pursed-lip breathing is a sign that does suggest there is expiratory airflow problems and therefore airways disease such as COPD.

    01:13 When you look at the chest though, it is frequently hyperexpanded. The ribs have come up the horizontal angle – to a more horizontal angle than usual, there’s an increased anteroposterior diameter. And when the patient breathes, there’s often what we call a tracheal tug where the cricothyroid cartilage comes down to the sternal notch on inspiration. And expansion is usually very obviously reduced bilaterally in patients with COPD. The trachea remains central because it’s a bilateral disease. And as I mentioned earlier, the percussion note, the resonance, the areas which are resonant might expand below the vertebral body of T10 posteriorly, over the liver anteriorly, and over the heart anteriorly. They may become resonant whereas previously they should have been – well, in normal people – they should be dull.

    02:02 If somebody has severe COPD, they’ll have central cyanosis and evidence of cor pulmonale and raised JVP and ankle oedema. When you listen to the lungs, the commonest sign is prolonged expiratory phase of the respiration and quiet breath sounds and, occasionally, you get a wheeze on expiration as well. But the absence of a wheeze does not mean they don’t have COPD.

    02:33 Pulmonary fibrosis (interstitial lung disease): so basal pulmonary fibrosis. It’s a disease that starts – idiopathic disease starts in the bases and moves up the chest as the patient get more severely affected. 10 to 15% of patients with fibrosis will have clubbing.

    02:49 However, that means 85% of patients will not. Expansion will be reduced bilaterally but not so obviously perhaps as it would be in COPD. Percussion note and vocal resonance will be normal.

    03:00 Really, the only sign that’s readily identifiable in patients with early pulmonary fibrosis are the crackles that you get. These crackles have a very specific nature which, with experience, you should be able to recognise as soon as you listen to them. And they’re called Velcro crepitations. They’re late inspiratory crackles, they occur in little bursts and that’s why they sound like Velcro being pulled apart. And they tend to occur – they occur over the areas of fibrosis which, in early disease, will be both bases. Some patients with pulmonary fibrosis have underlying rheumatoid arthritis with systemic sclerosis. And that may be obvious when you do the general examination that they have this connective-tissue disease as well.

    03:37 Obviously, with severe disease, you’d end up with central cyanosis, the crackles will have spread throughout both lungs and in fact the patient can even develop cor pulmonale just like COPD – end-stage COPD – might do as well.

    03:52 Bronchiectasis: that is another cause of clubbing. Again, it’s relatively uncommon in mild or moderate disease and really is only present in patients with a severe disease. You get bilateral reduced chest expansion if it’s a bilaterally-affected patient. Most patients with bronchiectasis are, but not all. But percussion note and vocal resonance will normal.

    04:11 And when you listen to the chest, again you’re going to hear basal crackles but, unlike fibrosis, these tend to be coarse crackles and can be associated with squeaks and wheezing as well.

    04:20 Again, if you’ve got severe disease, the patient will be breathless at rest, they’ll have central cyanosis. But, unlike lung fibrosis where the lungs become smaller as the disease becomes more severe, the reason why patients with bronchiectasis develop respiratory failure is due to associated airways obstruction. So you may have the signs that you get with COPD in somebody with severe bronchiectasis. So that will be hyperexpanded chest, pursed-lip breathing, prolonged expiratory phase, loss of dullness over the heart/liver, extent of the lungs below T10 for example. Occasionally, there might be evidence of the underlying cause of the bronchiectasis: rheumatoid hands, for example, situs inversus if it’s a ciliary dyskinesia problem.

    05:06 To summarise the main learning points of this lecture on the clinical examination: Examination is essential. You need to be able to identify signs that might confirm the diagnosis that you suspect after the history. But you also need to make sure there are no signs which are incompatible with the diagnosis that you’re suspecting and that you’re not going down the wrong route.

    05:25 Obviously, during acute presentations, you don’t actually have time to do investigations and you need to rely on your clinical examination skills to identify what’s wrong with the patient and give the appropriate treatment. And if that is not done effectively, then you run the risk of, well, essentially allowing the patient to die needlessly.

    05:42 To be able to examine a patient properly, you need a systematic approach to the examination to make sure you pick up all the abnormalities that might be present. And you need the knowledge to be able to interpret those abnormalities.

    05:54 Most of the major pathologies have distinct patterns of presentation when you do the examination.

    05:59 And you need to know these so that you don’t have to think hard about how to interpret the signs that you might identify. And therefore you can rapidly move on to doing the correct investigations and management and treatment that is required for the patient.

    06:13 Thank you for listening.

    About the Lecture

    The lecture Lung Examination: Fixed Airways Obstruction – Lung Disease by Jeremy Brown, PhD is from the course Introduction to the Respiratory System.

    Included Quiz Questions

    1. Extensive inspiratory crepitations
    2. Prolonged expiration phase
    3. Reduced expansion of the chest bilaterally
    4. Increased anterior-posterior diameter of the chest

    Author of lecture Lung Examination: Fixed Airways Obstruction – Lung Disease

     Jeremy Brown, PhD

    Jeremy Brown, PhD

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