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. 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.