This document provides information on performing a clinical assessment of the respiratory system. It discusses obtaining a history, performing a general examination including vital signs and systemic review, and examining the chest. It describes point of care devices like glucometers and pulse oximeters. Investigation methods covered include respiratory function tests, chest x-rays, and ECGs. Common respiratory symptoms like dyspnea, cough, hemoptysis, and chest pain are defined. Examination findings and adventitious lung sounds are also outlined.

1. • Clinical Assessment:
- History:
o Complaint (C/O): (Dyspnoea – cough – haemoptysis – chest pain)
o Present History.
o Past History.
o Other History: Family, Occupational, Drug, Operative,
Obstetric…
- General Examination:
o General look.
o Gait, decubitus, posture.
o Vital signs.
o Systemic review.
-
Diagnosis of Respiratory System Diseases

2. - Chest Examination:
o Inspection.
o Palpation.
o Percussion.
o Auscultation.
• Point of Care (POC) (Bed- Side or Hand- Held) Devices:
- Glucometer.
- Peak flowmeter.
- Pulse Oximeter.
• Respiratory Function Tests.
• Other Investigations:
- Chest X-Ray (CXR).
- Electrocardiography (ECG).

3. Dyspnoea: subjective feeling of difficulty in breathing due to
increased respiratory effort.
Exertional Dyspnoea: provoked or increased by physical activity.
Types
• Physiologic: with more than usual daily activity.
• Pathologic:
- Psychogenic: mainly at rest, with frequent sighing
- Organic
Grades
• Provoked by more than usual daily activity
• Provoked by usual daily activity
• Provoked by less than usual daily activity
• Present at rest
Dyspnoea

4. New York Hear Association (NYHA) Functional Classification
Of Heart Failure
What produces symptoms (dyspnoea, palpitations, fatigue)
and limitation of physical activity?
Class I: more than usual physical activity.
Class II: usual physical activity
Class III: less than usual physical activity
Class IV: without physical activity (symptoms at rest)

5. Progression to Grade 4 may occur over:
• Minutes (Acute Dyspnoea): foreign body aspiration, bronchial
asthma, pulmonary embolism
• Days: rapidly accumulating pleural effusion
• Months: interstitial lung disease
• Years: emphysema
• Orthopnoea
It is dyspnoea produced or aggravated on lying down,
relieved (partially or completely) in the upright position.
The flat position may impair ventilation of lower lung segments.
Orthopnoea may occur in heart failure and many chest disorders.
It may also result from abdominal distension pushing the diaphragm
upwards.

6. It is forced expiratory effort against a closed glottis which then suddenly
opens with a jet of air expelled out, possibly along with secretions.
Types
• Dry (Irritant) Cough: The irritant stimulus may be obvious (smoke, dust,
pharyngitis) and may not. Two common "concealed" causes of resistant
dry cough are post- nasal discharge and GERD (gastro-oesophageal
reflux disease).
Cough

7. • Wet (Productive) Cough:
Frothy Pink: pulmonary oedema
Mucoid: bronchial asthma, chronic bronchitis
Mucopurulent, Purulent (yellowish, thick): infections
Rusty: lobar pneumonia
Greenish/Bluish: Gram negative infection
Foul Smelling: anaerobic infection
Blackish: smoker, coal workers

8. It is coughing of blood or blood tinged sputum due to bleeding from the
respiratory tract below the vocal cords.
Bleeding originating above vocal cords (nose, mouth, larynx) may produce
false haemoptysis.
HaemoptysisHaemoptysis HaematemesisHaematemesis
It isIt is Coughing of bloodCoughing of blood Vomiting ofVomiting of
bloodblood
ColorColor Bright redBright red Dark redDark red
ReactionReaction alkalinealkaline acidicacidic
MixedMixed
withwith
Sputum, air (frothy)Sputum, air (frothy) foodfood
SputumSputum Blood tinged for 12 – 24Blood tinged for 12 – 24
h after the attackh after the attack
normalnormal
StoolStool normalnormal melenamelena
Hemoptysis

9. Non- Cardiac Cardiac
• Lung: pleurisy
• Oesophagus: GERD
• Stomach: gastritis, ulcer
• GB: cholecystitis
• Skin: Herpes Zoster
• Sickle cell crisis
Non- Ischemic
Ischemic
(Angina Pectoris)
• Expanding aortic
aneurysm
• Dissecting aortic
aneurysm
• Pericarditis
Non- Coronary Coronary
• Aortic stenosis
• Anaemia
• Fever
Not due to Coronary atherosclerosis
due to
Coronary
atherosclerosis
• Coronary arteritis
• Coronary embolism
Chest Pain

10. General Look
• Complexion: Pallor – Jaundice - Cyanosis
• Nutritional State: Malnutrition / Cachexia – Obesity
• Features related to systemic disease:
Diabetes mellitus – rheumatoid arthritis
• Features related to drug toxicity: cushinoid facies
Cyanosis bluish discoloration of skin, mucous membranes due to
presence of:
- > 5 gm deoxy Hb /100 mL blood
Or - abnormal Hb (met or sulph Hb)
in surface capillaries.
Normal level of deoxy Hb /100 mL blood:
- Arterial: 0.75 gm
- Capillary 2.25 gm
- Venous 3.75 gm

11. Consider average Hb: 15 gm/dL
Arterial
Blood
Capillary
Blood
Venous
Blood
Cyanosis is NOT a reliable sign to monitor the degree of
blood deoxygenation:
• Effect of Hb level.
• Effect of Hb type (MetHb – SulphHb)
• Effect of skin color.
Cyanosis is difficult to recognize in people
with dark skin.
Anemia
Polycythemia

12. ↑ O2
Extraction
↓ O2
Loading
Minor
(Pulmonary)
Circulation
Major
(Systemic)
Circulation
Central Cyanosis
This traditional clinical sign of
hypoxemia is insensitive bec.
apperas at < 80% O2 saturation.
Peripheral Cyanosis
This is a sign of poor
peripheral circulation.

13. Central CyanosisCentral Cyanosis
1
2
3
4
1) Hypoventilation
- ↓ alveolar PO2
: eg, high altitude
- Obstructive lung diseases
- Restrictive lung diseases
2) Shunt
- Cardiac Rt to Lt shunt (congenital
cyanotic heart disease): eg, Fallot
tetralogy
- Pulmonary: pulmonary AV fistula
3) Diffusion Defect (Alveolo-Capillary Block)
- Pulmonary fibrosis
- Pulmonary oedema
4) Ventilation Perfusion (V/Q) Mismatch
- Pulmonary embolism (ventilation > perfusion = dead space effect)
- Atelectasis/collapse (perfusion > ventilation = shunt effect)
- Most pulmonary disorders produce hypoxia by more than one
mechanism. V/Q mismatch is the most common.
Requisites for O2 Loading of
Blood in Pulmonary Circulation

14. Peripheral CyanosisPeripheral Cyanosis 1) Generalized stagnation (low
COP)
i. HF
ii. Shock
2) Localized stagnation
i. Arterial
• Lumen: thrombosis,
embolism
• Wall: Spasm:
Raynaud`s disease,
ergotism
• Outside: Compression
by a SOL
i. Venous
Chemical CyanosisChemical Cyanosis
1) Met-haemoglobin
2) Sulph-haemoglobin
The bnormal Hb causes:
- Dark color by itself.
- Reducing the normal Hb, bec it has much
higher affinity for O2

15. Central Cyanosis Peripheral Cyanosis
Cause ↓ O2
saturation of core
arterial blood (↓ O2
loading by
cardiopulmonary
circulation)
Stagnant circulation →
- ↓ peripheral arterial
flow
- ↑ O2
extraction by
tissues
Distribution Warm areas (tongue,
interior of lips), all over
Cold areas: tip of nose,
lobule of ear, fingers, toes
Temperature Warm Cold
Clubbing + -
Polycythaemia + -
Effect of
- Exercise
- Warming
- Oxygen
May ↑
No effect
↓ to variable extent,
maximal in low
atmospheric PO2
and
↓
↓
No effect

16. 1
4
3
2
O2 delivered to tissues
in amounts matching with metabolic needs
4 Prerequisites:
1) Load
2) Vehicle
3) Route
4) Unload
1) Loading of blood with O2 in alveoli.
2) Carrying of O2 by blood: Hb in intact RBCs.
3) Blood flow: intact circulation.
4) Extraction of O2 from blood by tissues.

17. 1
4
3
2
1) Hypoxaemia
Impaired blood oxygenation in alveolar capillaries
→ Low O2 tension in blood
2) Anaemia
Deficient Hb in intact RBCs
→ Low O2 carrying capacity of blood
3) Ischaemia
Circulatory insufficiency (local or general) →
blood supply not matching with metabolic needs
4) Tissue Toxins
Tissue inability to extract O2 (cyanide poisoning)
1) Hypoxic 2) Anaemic
3) Stagnant 4) Histotoxic
HYPOXIA
(Low O2 Tension
in tissues)

18. Hypoxia Low Oxygen Tension in tissues
Hypoxia Type Cyanosis
Hypoxic Hypoxia Central
Stagnant Hypoxia Peripheral
Anaemic Hypoxia ---
Histotoxic Hypoxia ---

19. Pulse Oximetry is a simple, relatively cheap, non- invasive technique to
monitor blood oxygenation.
It is a common POC device in ER, ICU, ambulance and even GP kit.

20. Principle Two LEDs are positioned on one side of the part examined,
with their respective photodetectors on the opposite side, with 5 – 10
mm of tissues intervening.
One LED emits red light (absorbed by deoxyHb).
The other LED emits infrared light (absorbed by oxyHb).
Relative absorption at each wave length is measured
(spectrophotometry) by the photodetector several times per second and
sent to a microprocessor that calculates the percent of oxyHb to total Hb
(which represents O2 saturation).
Q2 saturation readings are updated every 0.5 – 1 second so that they
average the readings over the last 3 seconds. That is why the oxymeter
reading should be taken 5 – 10 seconds after it is operated.
Oxygen Saturation of Blood =
Oxygen Content divided by
Oxygen carrying capacity
(2)
(2)

21. Indications for Oximetry
• Anaesthesia, sedation and perioperative use.
• Acute and chronic chest conditions (BA, COPD, pneumonia).
• Acute cardiac conditions (AMI, PE).
• CVS (cerebrovascular stroke).
• Acute metabolic derangements (DKA).
• Assessment of cardiorespiratory fitness (walking tests).
• Monitoring of oxygen therapy.
• Monitoring of mechanical ventilation.
• As alternative to ABG testing.
• Neonatal care.

22. Confounding Factors that may Influence Oximetry Reading
Medical Conditions
• Anemia or polycythemia → O2 Saturation does not reflect O2 content.
• Hypercapnoea (as in smokers): CarboxyHb is registered as 90% oxyHb
and 10% deoxyHb → overestimation of O2 saturation.
• Low peripheral perfusion → underestimation of O2 saturation, as in
shock, heart failure, cold weather.
Technical Factors
• Excessive movement.
• Strong ambient light (sun, infrared heater, phototherapy).
• Unopposing LED and detector.
• Automatic BP cuff → intermittent low reading.

23. Technique of Oximetry
• The pt should stay still during measurement. If oxymeter is used to
monitor effect of exercise, the pt should stay still a while whenever the
oxymeter reading is being taken.
• The probe may be placed on finger tip (usually index or middle finger)
or ear lobe. The latter is less accurate and less commonly used.
• The hand should be cleaned and dried; any nail polish removed.
• If hands were cold, warm them by rubbing against each other.
• The finger should fit snugly inside the oxymeter which should be
properly fixed (either clip or wrap style).
• The hand should be rested on the chest wall at the level of the heart,
rather than the digit is held in air (as patients commonly do) to minimize
motion artefact.

24. Technique of Oximetry (cont.)
• Most oxymeters record the pulse rate and waveform as well. This can
be used to confirm proper O2 saturation reading:
o Hear rate displayed by the oxymeter should conform with that
manually calculated (to indicate no motion artefact).
o Pulse waveform should be evident with dicrotic notch.
A flattened wave indicates poor perfusion.
• Avoid strong ambient light.
• Take the reading after it stabilizes after 5 – 10 seconds.
Maintenance of Oximeter
• Use a lightly damp cloth or paper towel to wipe away dust.
• Us an alcohol swab for disinfection.

25. General Recommendations Based on Oximetry Reading
95 – 100%
Normal
90 – 95%
• More frequent monitoring.
• Exclusion of low perfusion and technical factors causing low reading.
80 – 90%
Supplemental oxygen to ↑ saturation above 90%.
In most machines, the default low oxygen saturation alarm is 90%.
< 80%
• Check ABG.
• Consider ventilatory support.

26. Muscle wasting / CachexiaMuscle wasting / Cachexia
Obesity
Hypoventilation
Syndrome
• Complexion: Pallor – Jaundice - Cyanosis
• Nutritional State: Malnutrition / Cachexia – Obesity
• Features related to systemic disease:
Diabetes mellitus – rheumatoid arthritis
• Features related to drug toxicity: cushinoid facies

27. Acanthosis Nigricans
In diabetes mellitus
A band of
thickened
darkened skin
on the back of
the neck.

28. Rheumatoid Arthritis
May be associated
with Interstitial
pulmonary fibrosis
Sublaxation of MP joints with ulnar deviation
Hyperextension PIP joint,
Flexion DIP joint

29. Cushinoid Facies
Indicating Excess
Adrenocortical
Function
Face is puffy, plethoric and somewhat rounded (moon face), with acne.
Iatrogenic Cushing`s syndrome results from long standing treatment
with systemic corticosteroids, as in severe cases of bronchial asthma
and interstitial pulmonary fibrosis.
Systemic exposure to absorbed inhaled steroids is rarely significant.
Lomg term exposure to systemic steroids blunts the hypothalamic-
pituitary-adrenal axis. So, reduction of oral steroid dose or conversion
to inhaled steroids in cases with apparent cushinoid features should
be gradual to avoid precipitation of adrenocortical insufficiency.

30. Gait, Decubitus, Posture
• Gait: How the patient walks.
• Decubitus: How the patient lies in bed.
• Posture: particular part position.
Antalgic
Gait
Orthopnic
Decubitus
Pursed-Lip
Breathing

31. Vital Signs
Pulse - Blood Pressure – Respiration - Temperature
Normal Breathing
Cheyne Stokes Breathing
Acidotic (Kussmaul)
Breathing

32. Bilateral OLL Unilateral OLL
DVT → PE• Pulmonary hypertension → HF
• Hypoalbuminaemia:
o Malnutrition in cystic
fibrosis
o Copious sputum in
bronchiectasis
o Repeated Pleural tapping
SystemicReview

33. 33
Supraclavicular
Fossa
Infraclavicular
Fossa
Suprasternal
Fossa
Sternal
Angle
Subcostal (Epigastric)
Angle
Inspection

34. Infrascapular region
Interscapular region
Suprascapular region
Scapular region

35. Normal chest Barrel chest
(Hyperinflated Chest)
AP to
Transverse
diameter = 5:7
• AP to
Transverse
diameter = 1:1
• More
transverse ribs
and interspaces
• Obtuse
subcostal angle
• Dorsal
kyphosis
Characteristic of COPD

36. Kyphosis Scoliosis
Kyphoscoliosis
Restrictive Lung Disease

37. Suprasternal, Supraclavicular Retractions
Epigastric Retractions
Inetrcostal Retractions

38. Active Accessory Muscles of Respiration

39. Palpation
Trachea is markedly shifted to the left
It is either pushed away from Rt side (pleural effusion
or pneumothorax) or pulled to the Lt side (pulmonary
atelectasis or fibrosis).

40. Percussion
Penumothorax →
Hyperresonance

41. Breath Sounds
Auscultation

42. Adventitious Sounds
Wheezes (Rhonchi) Crepitations (Rales)
Pleural Friction Rub Stridor

43. Clinical Features ofClinical Features of
RESPIRATORY DISTRESSRESPIRATORY DISTRESS
SubjectiveSubjective
(Symptoms)(Symptoms)
ObjectiveObjective
(Signs)(Signs)
• Exertional dyspnoea
• Orthopnoea
• Tachypnoea (> 20 /min)
• Inspiratory Retractions
• Active accessory muscles of respiration
• Wheezes