So general observation: does the patient look
unwell? Do they have a fever? Patients with
pneumonia and other severe infections, they
look unwell. It’s obvious to anybody. It
doesn’t have to be a doctor. It could be
a lay person and they can tell that somebody
is unwell. And the temperature needs to be
measured. And if that’s high, then clearly
they have a pyrexia and we need to think about
what may be causing that pyrexia.
The level of consciousness surprisingly may
be – is an important component of the respiratory
examination, for acute presentations especially.
Because in fact, when you have acute respiratory
failure, the worse the respiratory failure
the more likely you are to end up becoming
drowsy. So reduced level of consciousness
is a very bad sign for somebody who has severe
respiratory failure in the acute situation.
Clearly for the respiratory examination, if
the patient has difficulty in breathing when
you’re examining them, that’s very important.
And there are a few things we need to look
One is: what is the pattern of the breathing?
And I’ll describe a few abnormal breathing
patterns in the next couple of slides.
The second is: are they using accessory muscles?
So, in the physiology lecture I described
how ventilation is normally an active process
on inspiration – requiring intercostal muscles
and the diaphragm – and a passive process
on expiration. But the skeletal muscles of
the chest wall, the abdomen and the neck are
not normally involved. But, when you have
ventilatory disorders and you’re dyspnoeic
and you have problems with severe breathlessness,
then you start to use those muscles – the
accessory muscles of breathing. So the sternocleidomastoids,
the trapezius. A patient may lean forward
and rest their arms so they can use their
pectoralis major and minor to help with their
respiration. And the abdominal muscles may
be working very hard indeed. These are all
evidence that the patient is struggling to
Pursed-lip breathing is an evidence of somebody
actually having a problem with airways obstruction.
Pursed-lip breathing is when the patient breathes
in and then breathes out against lips which
are slightly closed, like that. That is a
method of creating a little bit of end expiratory
pressure as the patient breathes out. And
the reason why that happens is that allows
the airways which, otherwise, may collapse
during expiration to be splinted open for
slightly longer. And it’s a sign that patients
with COPD have when they have bad airways
Intercostal recession is where the muscles
between the ribs sink in on inspiration and
it’s a sign that the patient really is struggling
with their breathing.
Another thing from the general examination
is: are there any visible chest wall or general
abnormalities? And I’ll discuss a few of
those in subsequent slides.
So abnormal types of breathing patterns: the
first of these is prolonged expiratory phase.
In normal respiration, inspiration is slightly
longer than expiration. However, in airways
disease, expiration is prolonged. So if you
can – if you observe that a patient is taking
longer over expiration than inspiration, that
is a very early sign that they have airways
disease in the examination process.
Cheyne-Stokes breathing is alternating slow
and fast respiratory rate. The patient breathes
fast, it slows down, it then stops and then
it starts back up again. After a few seconds,
it gets fast, slows down, stops for a few
seconds. That’s actually a sign not of respiratory
disease but normally of brainstem lesions
or, perhaps, pulmonary oedema. When people
have very severe pulmonary oedema, you see
a Cheyne-Stokes breathing pattern at the very
severe end of that disease.
Kussmaul is very fast, sighing respiration
caused by a metabolic acidosis. So that’s
where the low pH is driving a very fast respiratory
rate rather than a respiratory problem.
Like conscious level, an irregular breathing
pattern is a very bad sign. It means the patient
is struggling badly with very severe acute
respiratory problems and is likely to have
a cardiorespiratory arrest at any minute.
Stridor is a wheeze on inspiration. It’s
a very important sign because it identifies
somebody who may have upper-airways disease.
And those are a completely different type
of disease to lower airways. It requires a
different approach and can be, if it’s missed,
Excessive abdominal movements on inspiration
occurs because of this, as we’ve already
discusses, the issue about using your abdominal
muscles to help with respiration when you’re
struggling with your breathing.
Paradoxical abdominal movements is a very
unusual situation and only occurs when you
have significant diaphragmatic weakness. Normally
on inspiration, the diaphragms flatten. Then
the abdomen should go out. If the diaphragms
are actually paralysed, as you breathe in
using your intercostal muscles, the diaphragms
come up a bit. And that will draw in the abdomen.
So, if on inspiration the abdomen sinks in,
that’s called paradoxical breathing. And
that’s a very strong indication there’s
a respiratory muscle problem with the diaphragms.
So the visible abnormalities when examining
the chest and observing the patient in general
are: cachexia, marked loss of weight – we
have a very thin-looking patient. That occurs
in cancer, also in chronic infection and in
fact it occurs in severe airways obstruction
as well over time. Obesity is important because
it does identify patients who are at risk
of asthma because there’s an increased incidence
of asthma in people who are obese, obstructive
sleep apnoea and obesity hyperventilation.
If you have a single lung that has been shrunken
either by previous surgery or previous scarring
of some description, then that may be visible
from the end of the bed because the chest
wall will also be sunken slightly on that
side. And you can see that normally at the
top end of the chest where, if there’s a
small lung, it will have a flatter aspect
compared to the other side. And in fact when
a patient takes a breath and you can see there
will be less movement on the affected side
Surgical scars are very important. A thoracotomy
scar, obviously, might indicate somebody’s
had some form of major surgery of the lungs.
That could be a lung resection for whatever
reason. There could be pleural-drain scars.
These are very small, about that big. Normally
in the axillary region. Quite easily missed
but very relevant for people who may have
had pleural disease in the past. Mediastinoscopy
and mediastinotomy scars are surgical scars
that people have had lymph-node sampling done.
And the mediastinotomy scar will be here in
the sternal notch. And a sternotomy scar would
be just parallel to the sternum, somewhere
around the third- or fourth-rib area.
We talked about hyperexpanded chest quite
a lot in chest medicine. What we mean by that
is people with airways disease – because
expiration is a problem for them – they
end up in fact increasing the volume of their
lungs over time. So, on inspiration, they
breathe in more air than they expire. Slightly
different – slight gap in that volume. And,
over time, that leaves the chest being hyperexpanded
with the ribs more horizontal, the anteroposterior
diameter being larger than it should be. And
that’s visible in many patients with bad
A kyphoscoliosis is where there is a curvature
of the spine. A scoliosis is laterally, a
kyphosis is anteriorly. And that indicates
patients who may have problems with ventilation
of the lung because of the abnormality of
the curvature of the spine affects their skeletal
movements during respiration and, therefore,
Chest-wall masses are not common. Lipomas
are pretty common but they’re obvious when
you examine them that they are lipomas. But
the ones that really matter are tumours that
might be eroding through the chest wall. These
are rare but, when they happen, clearly they
are a very important sign. And there’ll
be a firm mass than you can feel. And it’s
rigid and fixed to the underlying chest wall.
Not normally tender.