Chest assessment

Original Editor - Mandeepa Kumawat Top Contributors - Kim Jackson, Mandeepa Kumawat and Adam Vallely Farrell

Introduction

Respiratory conditions can affect breathing either through damage to the lungs or excess secretions. To ensure that the correct treatment is implemented a thorough respiratory assessment is undertaken and should include both a comprehensive subjective and objective component to get a complete understanding of the client's function and baseline.[1][2]

Subjective Assessment

The subjective assessment is an important part of the client experience. It allows the client to express their symptoms from their viewpoint and helps to guide the objective assessment and plan a treatment programme with the clients needs at the forefront. Each subjective assessment should include the following components.[3][4]

  • Main Complaint:
  • History of Present Illness:
    • Site , Intensity , Type , Aggravating factor and Relieving factor (SITAR)
    • Onset - sudden or gradual
    • Location - radiating
    • Duration - frequency or chronology ( seasonal or daily variations )
    • Characteristics - quality or severity
    • Current situation - improving or deteriorating
    • Effect on activity of daily living (ADL)
    • Previous diagnosis of similar episodes
    • Previous treatment and efficacy
  • Past Medical History
    • Thoracic , nasal , pharyngeotracheal , trauma or surgery , hospitalisation for pulmonary disorders.
    • Use of ventilation - assisting devices
    • COPD- TB , bronchitis , emphysema , etc
    • Other chronic disorders - cardiac , cancer , blood clotting disorders
    • Allergy
    • Immunization (pneumococcal , influenza )
    • Diabetes Mellitus/ Tuberculosis/ Blood pressure/ asthma
  • Surgical History
    • Endoscopy , tracheostomy , lobectomy
  • Personal and social history
    • Sleep
    • Appetite / bowel , bladder / nutrition
    • Smoking
    • Exercise tolerance
    • Home environment
    • Economic condition - poor / fair / good

Cardinal Signs and Symptoms

Cough[5]

  • Onset: sudden or gradual
  • Duration: Acute < 3 weeks
  • Chronic: >3 weeks
  • Nature: Dry irritation; Wet signs of infection
  • Type: Mucoid; Mucopurulent TB; Frothy pulmonary oedema; Rusty (blood) TB , lobar pneumonia
  • Odour: foul infection

Sputum

  • Amount (tea spoon , table spoon , cup )
  • Normal - 100 ml of tracheobronchial secretions are produced daily and cleared subconsciously

Color

  • Blood streaked sputum inflammation of throat ( larynx , trachea ) or bronchi , lung cancer , ulcers
  • Pink sputum sputum and blood formed from alveoli and small peripheral bronchi
  • Copious amounts of blood - cavitary TB , lung abscess ,bronchieactasis , lung infarction , pulmonary embolism
  • Green or greenish coloured infection pneumonia , cystic fibrosis ( green from degenerative changes in cell debris )
  • Rust colored - pneumococcal bacteria , pulmonary TB
  • Brownish - chronic bronchitis ( greenish / yellowish / brown ) , chronic pneumonia ( whitish - brown )
  • Yellowish purulent - pus - haemophilus
  • Yellowish/green ( mucopurulent ) - treatment with antibiotics that reduce symptoms - bronchiectasis , cystic fibrosis , pneumonia
  • Whitish grey - chronic allergic bronchitis ( no. of eosinophilis )
  • White , milky or opaque (mucoid) - viral infection or allergy ( asthma )
  • Foamy white - earlier phase - pulmonary edema
  • Frothy pink - severe pulmonary edema
  • Black - black specks in mucoid secretions - smoke inhalation ( fires , tobacco , heroine ) , coaldust

Breathlessness

The physiotherapist should always relate breathlessness to the level of function that the patient can achieve

  • Exercise tolerance (e.g. number of stairs client can climb or can walk )
  • Shortness of breath at rest
  • Association of paraoxysmal nocturnal dyspnea (PND)
  • Associated swelling of ankles or recent weight gain
  • Activities : Sudden ( pneumothorax , pulmonary embolism , DVT )
  • Constant breathlessness ( fibrosis , fluid )
Grading Breathlessness
  • New York Heart Association (NYHA) Grade 1 - no symptoms and limitation in ordinary physical activity Grade 2 - mild symptoms , angina and slight limitation in ordinary activities Grade 3 - marked limitation in activity due to symptom , even during less than ordinary activity . Grade 4 - severe limitation , experience symptoms even at rest mostly bed bound patient
  • Modified Medical Research Council (MMRC) Grade 0 - no dyspnea except with strenous exercise Grade 1- dyspnea when walking up on the hill or hurrying on the level Grade 2 - walks slower than most on the level or stops after 15 minutes of walking on the level. Grade 3 - stops after few minutes of walking on the level. Grade 4- dyspnea with minimal activity such as getting dressed or too dyspneic to leave the house.
  • American Thoracic Society (ATS) Grade 0- none - no trouble of dyspnea on level / uphill Grade 1 - mild - dyspnea on at level / uphill. Grade 2 - moderate - walks slower than person of same age Grade 3 - severe - stops after 100 yards Grade 4 - very severe - breathlessness

Chest Pain

Chest pain in respiratory patients usually originate from musculoskeletal , pleural or tracheal inflammation as lung parenchyma and small airways contain no pain fibres. Pain relief can be achieved by heat, splinting or pain medication. Typical examples of the causes of chest pain include:

  • Pleuritic chest pain
  • Tracheitis
  • Musculoskeletal (chest wall) pain
  • Angina pectoris
  • Pericarditis

Incontinence

Coughing and huffing increases intra - abdominal pressure which may precipitate urinary leakage

Other Symptoms

  • Fever (pyrexia) - TB
  • Headache - morning headache - nocturnal CO2 retention
  • Peripheral oedema - right heart failure
  • Shivering
  • Weight loss
  • Palpitations
  • Vomiting and nausea
  • Gastro intestinal reflex

Objective Assessment

Once the subjective assessment has been completed there will indicators on what to look for during the objective assessment. A thorough and detailed objective assessment will assist with the planning and management of an individualised treatment programme that focuses on the presentation and needs of the client.[3][4]

General Examination

  • Vital signs
    • Temperature
    • Pulse
    • Respiratory rate
    • Blood pressure
    • Oxygen saturation (SpO2)
  • General Appearance
    • Ectomorph
    • Endomorph
    • Mesomorph
    • Body weight - BMI and weight in kg
    • Height
    • Nails - clubbing
    • Eyes - pallor (anaemia); Plethora (high haemoglobin); Jaundice (yellow color due to liver or blood disturbance)
    • Tongue and mouth - Cyanosis - hypoxemia
    • Jugular venous pressure - increased in right heart failure , chronic lung disease , dehydrated patient
    • Peripheral oedema - seen in decreased albumin level , impaired venous or lymphatic function , increased steroids
    • Pressure sores (in bedbound patients)
  • Observation of Chest
    • Tranverse diameter > AP Diameter
    • Kyphosis
    • Kyphoscoliosis - restrictive lung defect
    • Pectus carinatum - pigeon chest
    • Hyperinflation or barrel chest - AP = transverse - ribs horizontal
  • Breathing Pattern
    • Typical rate - 12 to 16 breath per minute
    • Typical Inspiratory : expiratory ratio = 1:1.5 to 1:2
    • Check for bradypnea , tachypnea , hyperventilation
    • Prolonged expiration - 1:3 to 1:4
    • Pursed lip breathing
    • Apnoea
    • Hypopnea
    • Kaussamaul ‘s respiration - metabolic acidosis
    • Cheyne strokes respiration - drugs ( narcotics) , heart failure , neurological disturbances
    • Ataxic breathing - cerebellar disease
    • Apneutic breathing - brain damage
    • Thoracoabdominal - female ; abdominothoracic
  • ICU Patients
    • Mode of ventilation - supplemental oxygen; intermitent positive pressure ventilation
    • Route of ventilation - face mask, nasal cannula, endotracheal tube, tracheostomy
    • Level of consciousness - measured with Glasgow coma scale
    • Central venous pressure (CVP) and pulmonary artery pressure (PAP)
  • Palpation
    • Trachea - tracheal deviation indicates underlying mediasternal shift . trachea may be pulled towards in collapsed or fibrosed upper lobe or pushed away from pneumothorax or large pleural effusion .
  • Measuring Chest Expansion (using a tape measure) Technique at residual volume , the examiner ‘s hands are placed spanning the posterolateral segment of both bases , with the thumbs touching in the midline posteriorly . both the sides should move equally with 3 - 5 cm being the normal displacement.
    • Supramammary - 1.5cm
    • Mammary - 1.5 cm
    • Inframammary - 1cm
  • Hoover’s sign Paradoxical movement of the lower chest can occur in patients with severe chronic airflow limitation who are extremely hyperinflated . as the dome of the diaphragm cannot descend any further diaphragm contraction during inspiration pulls the lower ribs inwards. This is called hoover’ s sign.
  • Vocal Fremitus It is the measure of speech vibrations transmitted through the chest wall to the examiner’ s hands .It is the measure by asking the patient to repeatedly say ‘ggg’ or 111 whilst the examiner`s hands are placed flat on both sides of the chest
    • Increase in patient whose lung underneath is relatively solid ( consolidated)
    • Decrease in patient - pneumothorax or pleural effusion
  • Percussion It is performed by placing the left hand firmly on the chest wall so that the finger have good contact with the skin . the middle finger of the left hand is struck over the DIP joint with the middle finger of the right hand . for all the positions , percuss at 4 to 5 cm intervals over the intercostal spaces , moving systematically from superior to inferior and medial to lateral
  • Resonance - the expected sound can usually be heard over all areas of the lungs.
    • Hyper resonance - associated with hyperinflation may indicate emphysema , pneumothorax or asthma.
    • Dullness or flatness - pneumonia , atelactasis , pleural effusion , pneumothorax or asthma.
    • Tympany - sound usually associated with percussion over the abdomen
  • Auscultion Auscultation with the stethscope provides important clues to the condition of the lungs and pleura. all sounds can be characterized in the same manner as the percussion notes, intensity, pitch, quality and duration.
    • Normal breath sounds bronchial, vesicular
    • Abnormal breath sounds - crackles, rhonchi, wheeze, pleural friction rub
    • Vocal resonance - Transmission of voice through the airway and lung tissue to the chest wall where it is heard through a stethoscope, it is usually tested by instructing the patient to say ‘99’ repeatedly.
      • Decrease in resonance - emphysema , pneumothorax , pleural thickening or pleural effusion.
    • Heart sounds
      • 1st - closure of mitral and tricuspid valve.
      • 2nd - closure of pulmonary and aortic valves.
      • 3rd - cardiac failure
      • 4th - heart failure , hypertension , aortic valve disease

Diagnostics

There are many different tests that can assist in diagnosing respiratory conditions and help implement and guide the best treatment options.

Spirometry

This is a simple respiratory test that measures the forced expiratory volume in 1 second (FEV) , the forced vital capacity ( FVC ) and peak expiratory flow rate (PEFR) are important measures of ventilatory function.[6]

Arterial Blood Gases

ABG provide an accurate measure of O2 uptake and CO2 removal by the respiratory system as a whole. Typical values are listed below:

  • pH : 7.35 TO 7.45
  • PaO2: 10.7 to 13.3 kPa ( 80 - 100 mmHg)
  • PaCO2: 4.7 TO 6.0 KPa (35 to 45 mm hg)
  • HCO3: 22 - 26 MMOL / L
  • Base excess : -2 to +2

Chest x-ray

Chest x-rays are often taken early if a respiratory disorder is suspected. As well as revealing the condition of the lungs they can also diagnose:

  • Pneumonia
  • Emphysema
  • Mass or nodule in the lung
  • Pleural effusion (fluid around the lung)
  • Rib fracture
  • Tuberculosis
  • Congestive heart failure
  • Enlarged heart

References

  1. Mikelsons, C. (2008). The role of physiotherapy in the management of COPD. Respiratory Medicine: COPD Update, 4(1), 2–7
  2. Cross J, Harden B, Broad MA, Quint M, Paul Ritson MC, Thomas S. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2008 Nov 25.
  3. 3.0 3.1 Hough A. Physiotherapy in respiratory care: a problem-solving approach to respiratory and cardiac management. Springer; 2013 Nov 11.
  4. 4.0 4.1 Main E, Denehy L. Cardiorespiratory Physiotherapy: Adults and Paediatrics 5th Edition. Elsevier; 2016 Jul 5.
  5. Raj, A. A., & Birring, S. S. (2007). Clinical assessment of chronic cough severity. Pulmonary Pharmacology & Therapeutics, 20(4), 334–337.
  6. Miller MR, Hankinson J, Brusasco V et al (2005) Standardisation of spirometry. Eur Respir J 26(2):319–338