ASSESSMENT OF RESPIRATORY
DISEASES
CHAPTER III
Text book : Essentials of Cardio
Pulmonary Physical Therapy
Page no : 534-566
SUBJECTIVE ASSESSMENT
 NAME
:
 AGE
:
 SEX
:
 OCCUPATION
:
 ADDRESS
:
 ETHNICITY
:
 MARITAL STATUS
:
 DATE OF ADMISSION
:
 IP(INPATIENT)WARD NO
:
SUBJECTIVE ASSESSMENT
HISTORY TAKING
 History taking is a very critical part of the examination
 Most of the cases, you can actually be able make a diagnosis based on the
history alone.
 An ability to listen & ask common-sense questions that help define the
nature of a particular problem.
 A Information can be obtained from
- History
- Medical chart
- Patient / Family interview
- Other members of the team treating the patient
CHIEF COMPLAINT
 What brings your here?
 The patient describe the problem in their own words and the same
should be recorded
 Usually a single symptoms, occasionally more than one complaints
like
Chest pain,
Palpitation ( Feeling of one’s own breath)
Shortness of breath (breathlessness),
Cough
Blood present in the sputum etc.,
Present complaint
The main respiratory symptoms are:
 Dyspnea (Breathlessness).
 Dyspnea on exertion
 Cough
 Sputum Production
 Improved work of breathing
 Audible Wheezing
 Chest pain
Other systems
 Loss of appetite
 Significant loss of weight e.g. malignancy or tuberculosis.
 Upper gastrointestinal symptoms: gastro-oesophageal reflux is a common
cause of chronic cough.
 Heart disease may cause respiratory symptoms. Are there any indications
of heart failure or ischemic heart disease
 Severe anemia may cause breathlessness.
 Rheumatoid arthritis and other connective tissue diseases may cause
respiratory symptoms.
 Neuromuscular diseases may cause respiratory symptoms, particularly
dyspnea.
PAST MEDICAL HISTORY
 Past health including Childhood illnesses, accidents or injuries.
 Chronic illnesses and Hospitalization( If yes prognosis and Duration).
 Malignant disease (Pulmonary Metastases).
 Infections including Pneumonia, Tuberculosis and Whooping cough
 Chest trauma (Fracture) and Surgeries.
 Thrombo embolic disease, specifically Deep vein thrombosis (DVT) and
Pulmonary embolus
 History of other system disorders like Cardiovascular, Neurological,
Orthopedical and Psychological disorders leads to respiratory
problem.
Medications history
Drug history
Knowledge of the patient’s medications can provide
information about the patient’s present or recent
past medical history like medications for Hypertension, Heart failure,
Angina, Bronchospasm and Infections.
Example
 Use of inhalers (Assess compliance and technique).
 Use of Steroids (Some measure of severity in asthma).
 Other drugs which may have relevance in respiratory disease, e.g.
angiotensin-converting enzyme (ACE) inhibitors for hypertension may
cause Dry cough.
Allergic History
 Ask about all allergies including, for example, food, inhaled
allergens and drugs.
Occupational history
An occupational history may be very important in
respiratory disease.
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Asbestosis
Extrinsic Allergic Alveolitis
Pneumoconiosis
Byssinosis
Industrial Dust Diseases
Home environment / Family situation / Social history
 Supportive family is important to the success of rehabilitation of any patient
 Negative family environment can deter the rehabilitation
Personal history / Smoking history
The type and number of cigarettes smoked currently and in the past. Ask also
about passive smoking.
Lifestyle and alcohol consumption are also very relevant to
respiratory diseases. Ask about illicit drugs.
Hobbies and pet animals may also be responsible for respiratory disease.
(Extrinsic Bronchial asthma)
Sexual history may be relevant to risk of HIV and AIDS.
Family history
 Respiratory diseases with a genetic component, e.g.
Cystic fibrosis, Emphysema (alpha-1-antitrypsin
deficiency)
 Infectious diseases such as tuberculosis (remember high-
risk groups).
 Atopic diseases such as asthma, hay fever and eczema.
VITAL SIGNS
1. Body Temperature (T)
2. Pulse (P)
3. Respiratory rate (RR)
4. Blood pressure (BP)
5. O2 saturation ( Spo2)
1. Body Temperature (T)
Normal range - 37˚C or 98.6˚ F
If more than normal – Pyrexia or Hyperthermia
If Temperature more than 41˚C or 105.8˚ F - Hyperpyrexia
If Temperature below 35.0 °C or 95° F - Hypothermia
2. Pulse (P)
A pulse is a rhythmic arterial blood pressure throb created by the pumping action
of the ventricular muscles. It is assessed by palpation.
There are 9 common sites to palpate the pulse includes carotid, brachial, radial,
femoral, popliteal, dorsalis pedis, and posterior tibial area.
Normal Heart rate
Infants (0 to 1 year)
- 100 to 160 beats/mins
Toddler ( 1 to 3 years)
- 90 to 150 beats/mins
Preschooler ( 3 to 6 years)
- 80 to 140 beats/mins
Elementary school age ( 6 to 12 years) - 70 to 120 beats/mins
Adolescent ( 12 to 18 years)
- 60 to 100 beats/mins
Adult (18+ years)
- 60 to 100 beats/mins
Abnormalities
Heart rate lower than 60
Greater than 100
- Bradycardia
- Tachycardia
3. Respiratory rate (R)
The number of breaths a person takes during one minute.
Normal respiration rate at rest range from 12-20 breaths/ minute
Infants (0 to 1 year)
- 30 to 60 breaths / mins
Toddler ( 1 to 3 years)
- 24 to 40 breaths / mins
Preschooler ( 3 to 6 years)
- 22 to 34 breaths / mins
Elementary school age ( 6 to 12 years) - 18 to 30 breaths / mins
Adolescent ( 12 to 18 years)
- 12 to 16 breaths / mins
Adult (18+ years)
- 12 to 20 breaths / mins
Breathing patterns
Apnea
- Absence of Ventilation
Eupnea
- Normal rate, Normal depth, regular rhythm
Hyperventilation - Fast rate and increased depth.
Tachypnea
- Faster rate, Shallow depth , regular rhythm
Bradypnea - Slow rate, shallow or normal depth, regular rhythm
Orthopnea - Difficulty breathing in postures other than erect
Dyspnea
- Rapid rate, Shallow depth, regular rhythm ; associated
with accessory muscle activity
Fish-mouth - Apnea with concomitant mouth opening and closing
associated with neck extension and bradypnea
Cheyne-stokes - Increasing then decreasing depth, period of apnea
interspersed ; somewhat regular rhythm ; associated
with critically ill patients
4. Blood pressure (BP)
 Blood Pressure- measurement of the force exerted by blood against the
walls of the arteries
 Systolic blood pressure- the pressure in the large arteries when the
heart is contracted
 Diastolic Blood pressure- the pressure in the large arteries when the
heart is relaxed
Normal BP – 120±20/80±10
If Pressure goes ABOVE 140 ( Systolic) or 90 ( Diastolic) – Hypertension
If Pressure goes BELOW 100 ( Systolic) or 70 ( Diastolic) - Hypotension
02 saturation (SpO2)
 SpO2 Is a measurement of the amount of oxygen attached
to the hemoglobin cell in the circulatory system.
 Normal percentage of SpO2 is 98% to 100%
 Caution should be taken with patients who desaturate
with activity below 90 %
 Exercise should not be continued of oxygen saturation
drops to 88 %
Physical Examination
1. Inspection
2. Palpation
3. Mediate Percussion
4. Auscultation of the lungs
5. Investigation
1. On Inspection
INSPECTION IS EXTREMELY IMPORTANT IN PATIENTS WITH PULMONARY
DYSFUNCTION.
GENERAL APPEARANCE
Level of consciousness – Alert, agitated, Confused, Semi comatose, Comatose
Observation of body type – Obese, normal, Cachectic
Posture and positioning - Their impact on pulmonary system.
Skin tone – It indicates the general level of oxygenation and perfusion
External monitoring and Support equipment
On Inspection - Face
 Facial expression and effort to breathe
 Facial signs of distress includes Nasal flaring, Sweating, Paleness,
and focused, or enlarged pupil
 Pursed lip breathing ( Is a sign of COPD)
 Central cyanosis.
 Anemia (conjunctivae).
 Horner's syndrome- Combination of drooping of the eyelid(ptosis)
and constriction of the pupil (miosis) (possible apical lung cancer).
Horner’s syndrome
On Inspection - Neck:
 Activity of the neck musculature during breathing – There may be
hypertrophy of sternocleido mastoid muscle (Indicates chronic pulmonary
condition)
 Adaptive shortening of sternocleido mastoid muscle and clavicle appears
more prominent (Indicates chronic forward bent posture)
 Distended (Swelling)Jugular veins in sitting or recumbent position with
head elevated at least 45 degrees (Indicates increased volume in the
venous system – it may an early sign of right side heart failure (Cor
pulmonale)
 Goitre - It is a swelling
in the thyroid gland
 Lymphadenopathy
On Inspection - Chest
THE RESTING CHEST IS EVALUATED for its symmetry, configuration, rib
angles and intercostal spaces and musculature.
 There may be hypertrophy of scalenes, trapezius, and intercostals
indicates diminished work of diaphragm muscle.
 Abnormal chest shapes and configuration
- Funnel chest (Pectus excavatum)
- Pectus carinatum(Pigeon chest)
- Lordosis
- Kyphosis
- Scoliosis
 Operation scars.
 Trauma
 Chest drains and Tubes
- Depression of sternum
- Protrusion of the sternum
- Anterior curvature of spine
- Posterior curvature of spine
- Lateral curvature of spine
THE MOVING CHEST WALL MUST BE EVALUATED for its
Breathing pattern, rates, inspiratory to expiratory ratios (I:E
ratio), and symmetry of chest wall motion.
 Breathing pattern – Movement of chest wall and paradoxical
breathing pattern (Breathing movements in which the chest
wall moves in on inspiration and out on expiration) can be
noted with COPD and Neurological assault and respiratory
distress in child.
 Respiratory rate – Should be assessed subconsciously for 1 full
minute
 I:E ratio – Normal is 1:2 ( With asthmatics it can be 1:4)
On Inspection – Phonation, cough and
Cough production)
 Dyspnea on phonation – When speech is interrupted for
breath. Should see how many words can be expressed
before next breath.
 Cough should be assessed for strength, depth, and length
of cough.
 Secretions (Sputum) should be assessed for quantity,
color, smell and consistency.
On Inspection -Extremities
 Digital clubbing-Loss of the normal ( less than165° )angle (Lovibond angle)
between the nail bed and nail. It indicates chronic tissue hypoxia.
 Cyanosis-Cyanosis is a bluish discoloration of the skin and mucous
membranes. (Common in :COPD, Pulmonary Hypertension, Pulmonary
embolism, Hypoventilation)
Central cyanosis
-Seen on the tongue and mouth, is caused
by hypoxemia
Peripheral cyanosis
- Affecting the toes, fingers and earlobes may
also be due to poor peripheral circulation
 Tobacco staining.
 A tremor may indicate carbon dioxide retention.
Clubbing
Cyanosis
On Palpation-Trachea
 Firstly, the trachea is palpated to assess its position in relation to the
sternal notch.
 Trachea can shifted due to disproportionate intra thoracic pressure or lung
volumes between two sides of thorax.
TRACHEAL DEVIATION INDICATES UNDERLYING MEDIASTINAL SHIFT .
Pleural Effusion, Untreated Pneumothorax and tumor (when there is
increased pressure on same side) – Contents SHIFTS TO UNAFFECTED SIDE
Lobectomy, Pneumonectomy, Pulmonary fibrosis and large degree of
Atelectasis ( When the lung volume and pressure is decreased) – Contents
SHIFTS TOWARDS AFFECTED SIDE
On Palpation-Chest excursion
 Symmetrical reduction: Overinflated lungs (e.g. bronchial
asthma, emphysema), stiff lungs (e.g. pulmonary
fibrosis, ankylosing spondylitis).
 Asymmetrical reduction of chest wall expansion: absent
expansion (e.g. empyema and pleural effusion) or reduced
expansion (e.g. pulmonary consolidation and collapse).
 Usual chest expansion in an adult is 2-3 Inches and should
be symmetrical.
MEASUREMENT OF CHEST EXCURSION
 Take a Inch tape and encircle chest around the level of
nipple. Take measurements at the end of deep inspiration
and expiration.
 Normally, a 2-3 Inches of chest expansion can be
observed.
On Palpation-Tactile vocal Fremitus
Tactile vocal Fremitus : Fremitus is defined as the vibration that is
produced by the voice or by the presence of secretions in the airways
and is transmitted to the chest wall and palpated by the hand
Whilst the examiner's hands are placed flat on both sides of the
chest. The hands are moved from apices to bases, anteriorly and
posteriorly, comparing the vibration felt. Each time asking the patient
to say "ninety-nine“ (99). Note how the sound is transmitted to the hand.
 Tactile vocal Fremitus is INCREASED with the presence of secretions and over
areas of consolidation (E.g. Pulmonary fibrosis, Pulmonary edema,
Atelectasis and Lung tumors)
 Tactile vocal Fremitus is DECREASED or ABSENT with more air in that area and
over areas of effusion or collapse(E.g. Pleural effusion, Pneumothorax,
COPD)
2.ASSESSMENT OF COMMON
SYMPTOMS
There are five main symptoms of respiratory disease:
 Breathlessness (Dyspnea)
 Cough
 Sputum and hemoptysis
 Wheeze
 Chest pain.
With each of these symptoms, enquiries should be made
concerning:
 Duration - both the absolute time since first recognition of
the symptom (months, years) and the duration of the present
symptoms (days, weeks)
 Severity - in absolute terms and relative to the recent and
distant past
 Pattern - seasonal or daily variations
 Associated factors - including precipitants, relieving factors,
and associated symptoms, if any.
Rate of perceived exertion (RPE) or Borg scale
(Dyspnea scale)
It can be assessed by
BORG RATING PERCEIVED EXERTION SCALE
0
Nothing at all
0.5
Very, very weak (just noticeable)
1
Very weak
2
Weak (light)
3
Moderate
4
Somewhat strong
5
Strong (heavy)
67
Very Strong
8910
Maximal
MODIFIED
BORG RATING SCALE FOR PERCEIVED DYSPNEA
0
0.5
Nothing at all
Very, very slight shortness of breath
1
Very mild shortness of breath
2
Mild shortness of breath
3
Moderate shortness of breath or breathing difficulty
4
Somewhat severe
5
Strong or hard breathing
6
-
7
Severe shortness of breath or very hard breathing
8
-
9
Extremely severe
10
Shortness of breath so severe you need to stop
2. Cough and sputum
Coughing is a protective reflex which get rids of secretions or
foreign bodies from the airways.
Sputum
 In a normal adult, approximately 100 ml of tracheobronchial secretions
(Mucus) are produced daily and cleared subconsciously.
 Sputum is the excess tracheobronchial secretions that is cleared from the
airways by coughing or huffing.
 It may contain mucus, cellular débris, micro organisms,blood and foreign
particles.
 Haemoptysis is the presence of blood in the sputum(e.g.
aspiration pneumonia, lung abscess).
CHARACTERISTICS OF COUGH
Nonspecific cough (Running nose)
INTERPRETATION
Acute lung infection
Productive Cough
Lobar pneumonia
Purulent sputum
Acute exacerbation of Chronic bronchitis
Productive for at least 3 months of the
year for at least two consecutive years.
Chronic bronchitis
Foul smelling, Copious, layered sputum
Bronchiectasis
Blood tinged sputum ( a month long)
Tuberculosis
Persistent, Non productive cough
Interstitial fibrosis
Persistent, Non productive cough
“Smokers cough”
Characteristics
 Saliva
- Clear watery fluid
 Mucoid
- Opalescent or white
 Mucopurulent
- Slightly discolored, but not frank pus
 Purulent
- Thick, viscous: Yellow
Dark green/brown
Rusty Red currant jelly
Grading of sputum
M1
M2
P1
P2
P3
-
Mucoid with no suspicion of pus
Predominantly mucoid, suspicion of pus
1/3 purulent, 2 /3 mucoid
2/3 purulent 1/3 mucoid
More than 2 / 3 purulent
Chest pain
Chest pain in respiratory patients usually originates from
musculoskeletal, pleural or tracheal inflammation, as the lung
parenchyma and small airways contain no pain fibres.
 Pleuritic chest pain
It is caused by inflammation of the parietal pleura, and is
usually described as a severe, sharp, stabbing pain which is
worse on inspiration. It is not reproduced by palpation.
 Tracheitis generally causes a constant burning pain in the
centre of the chest aggravated by breathing.
 Musculoskeletal (chest wall) pain
May originate from the muscles, bones, joints or
nerves of the thoracic cage. It is usually well localized
and exacerbated by chest and/or arm movement.
Palpation will usually reproduce the pain.
 Angina pectoris
It is a major symptom of cardiac disease. Myocardial
ischemia characteristically causes a dull central
retrosternal gripping or band-like sensation which may
radiate to either arm, neck or jaw.
ASCULTATION
Breath Sounds
Normal
Abnormal
Adventitious
Bronchial or
Tracheal
Absent/decreased
Crackles (rales)
Broncho vesicular
Bronchial/Increased
Wheeze
Vesicular
Rhonchi
Stridor
Pleural rub
1. Normal Breath Sounds
Breath sounds are created by turbulent air flow.
In Inspiration, air moves into progressively smaller
airways with the alveoli as its final location. As air hits
the walls of these airways, turbulence is created and
produces sound.
In Expiration, air is moving in the opposite direction
towards progressively larger airways, thus normal
expiratory breath sounds are quieter than inspiratory
breath sounds.
1)Tracheal or Bronchial Breath Sound
Bronchial breath sounds are very loud, high-pitched.
There is a Pause (gap) between the inspiratory and expiratory
phases of respiration, and the expiratory sounds are longer than
the inspiratory sounds.
Place of Auscultation - Over the trachea
2) Broncho vesicular Breath Sound
These are of Moderate intensity and softer pitch than bronchial
sounds. The inspiratory and expiratory sounds are equal in length.
Anteriorly, these sounds can be ascultated directly over the main stem
bronchi (Between 1 st and 2 nd ribs) and Posteriorly, they can be ascultated between
the scapulae ( Between 1 to 6 ribs)
3)Vesicular Breath Sound
The vesicular breath sound is the major normal breath sound and is heard
over most of the lungs. They sound soft and low-pitched.
The inspiratory sounds are longer than the expiratory sounds.
Broncho Vesicular sound
Vesicular sounds
2. Abnormal Breath Sounds
1. Absent or Decreased Breath Sounds
There are a number of common causes for
abnormal breath sounds, including: COPD, Pleural
Effusion, Pneumothorax, Hypo inflation and
hyperinflation.
2. Bronchial Breath Sounds in Abnormal Locations or
Increased breath sounds
Bronchial breath sounds occur over consolidated areas.
3. Adventitious Breath Sounds
1.Crackles (Rales)
Crackles are discontinuous, nonmusical sounds like brief
bursts of popping bubbles. More commonly heard during
inspiration.
The mechanical basis of crackles: Sudden opening of closed
airways.
Conditions:
Atelectasis, Fibrosis, Bronchiectasis, Chronic bronchitis,
Consolidation, Pleural effusion, and Pulmonary edema
2. Wheeze
Wheezes are continuous, high pitched, Whistling sounds most
commonly heard on expiration.
Wheezes are produced when air flows through airways narrowed by
secretions, foreign bodies, or obstructive lesions.
Conditions:
Asthma, CHF, Chronic bronchitis, COPD and Pulmonary edema
3. Rhonchi
Rhonchi are low pitched, continuous, musical sounds that are
similar to wheezes. They usually imply obstruction of a larger airway by
secretions.
Common in Cystic fibrosis and Pneumonia
4. Stridor
Stridor is an musical sound heard loudest over the trachea
during inspiration. Stridor suggests an obstructed trachea or
larynx.
This is common in Asthma, Laryngo spasm and Neoplasm
5. Pleural Rub
Pleural rubs sounds Like two pieces of leather or sand paper
rubbing together. Produced when the pleural surfaces are
inflamed and rub against each other. It is usually heard in lower
lateral chest areas.
Conditions: Pleural effusion, Pneumothorax
PERCUSSION
 Percussion is the FINAL component of chest examination
and is performed to further evaluate changes in lung
density and to evaluate the extent of Diaphragmatic
excursion.
 Percussion is performed with the middle finger of the
Non dominant hand placed flat on the chest wall along
the intercostal space between two ribs and other hand
positioned with the wrist in flexion and do strike the
finger.
Resonant sounds
It is low pitched, hollow sounds heard over normal
lung tissue.
Dull sounds
 It is normally heard over dense areas such as the liver or
heart. It is described as “THUD”
Dullness will be heard when fluid or solid tissue
replaces air-containing lung tissues, such as occurs with
pneumonia, pleural effusions, tumors, Atelectasis, and
pleural thickening.
Hyper resonant sounds
That are louder and lower pitched than resonant sounds are
normally heard when percussing the chests of children and very thin
adults.
Hyper resonant sounds may also be heard when percussing lungs
hyper inflated with air, such as may occur in patients with COPD, or
patients having an acute asthmatic attack. An area of hyper resonance
on one side of the chest may indicate a Pneumothorax.
Tympanic sounds
These are hollow, high, drum like sounds. Tympany is
normally heard over the stomach, but is not a normal chest sound.
Tympanic sounds heard over the chest indicate excessive air in the
chest, such as may occur with Pneumothorax.
Diaphragmatic Excursion
 Diaphragmatic excursion can also be assessed by percussion.
 It is performed by asking the patient to exhale and hold it. The
therapist then percusses down their back in the intercostal
margins, starting below the scapula, until sounds change from
resonant to dull (lungs are resonant, solid organs should be
dull). Mark the point with the pen.
 Then the patient takes a deep breath in and holds it, marking
the spot where the sound changes from resonant to dull again.
 Then measure the distance between the two spots. Repeat on
the other side, is usually higher up on the right side. Normal
excrsion is 3–5 cm.
 Excursion of Diaphragm may be decreased with COPD.