OnExam

Vital Signs


Assessing vital signs.

  • During the respiratory physical examination, the patient should be disrobed from the waist up, with appropriate draping, depending on the area being examined.
  • Inspection

    • Observe the rate (RR), rhythm, depth and effort
      • Normal adult RR: 14-20 breaths/minute
      • Normal pediatric RR
      • Abnormal Reespiration
        • Hyperpnea: deep breathing
        • Hyperventilation: rapid breathing
        • Obstructive breathing: prolonged expiratory phase
        • Cheyne-Stokes breathing: cyclic crescendo-decrescendo respiratory effort (rate and volume) followed by periods of apnea
        • Kussmaul breathing: deep breathing with metabolic acidosis; rate may be fast, slow or normal
        • Ataxic breathing: irregular and unpredictable breathing which may be shallow or deep and may stop for periods of time
    • Signs of respiratory distress
      • Accessory muscle use
      • Tripod position
      • Pursed-lipped breathing
      • Intercostal in-drawing
      • Tracheal tug
      • Stridor
      • Displacement of trachea from midline
      • Cyanosis
        • Paradoxical breathing: inward movement of abdomen with inspiration
      • Chest expansion (equal bilaterally)
      • Skin colour
        • Central cyanosis: lips, frenulum, nuccal mucosa
        • Peripheral cyanosis: fingers, toes, ears, nose
      • Clubbing and Schamroth sign.
      • Chest deformities or asymmetry
        • Pectus excavatum: marked depression in the lower portion of the sternum that can impair cardiac and respiratory function
          • Can impair cardiac and respiratory function
        • Pectus carinatum: protrusion of the sternum and ribs
        • Barrel chest: increased AP diameter resulting in a round shaped thorax
        • Flail chest: multiple sequential rib fractures forming an independently mobile segment of chest
          • Paradoxical movement: chest moves inward during inspiration and outward on expiration
        • Abnormal spinal curvatures(e.g., kyphosis, scoliosis, kyphoscoliosis)
          • Can impede clinical examination, alter work of breathing, and create a V/Q mismatch

    Palpation

    • Assess both anterior and posterior chest
    • Palpate the entire chest, with focus on tender areas and any abnormalities noted on inspection
    • A/P compression for fractured ribs
    • Palpate trachea to assess whether it is midline
    • Assess chest expansion
    • Assess tactile vocal fremitus

    Percussion

    • Use ladder-like pattern along the posterior and anterior chest to compare for symmetry
    • Five percussion notes
      • Flatness (bone)
      • Dullness (diaphragm, masses, fluid)
        • Note: Cardiac dullness is normal on left 3rd to 5th intercostal spaces
      • Resonance (lungs)
      • Hyperresonance (hyperinflated lungs)
      • Tympany (abdomen)
    • Percuss diaphragmatic excursion

    Auscultation

    • Assess both anterior and posterior chest
    • Ask the patient to breathe with their mouth open
    • Posterior chest: arms crossed over their chest to move the scapulae laterally
    • Use diaphragm of stethoscope and similar ladder-type pattern as for percussion, sweeping from side to side comparing symmetry at each level
    • Listen for major breath sounds and adventitious breath sounds (both outlined below)
      • If bronchovesicular or bronchial breath sounds are heard in locations where vesicular sounds are expected, suspect that air filled lung has been replaced by fluid filled or solid lung tissue

    Normal Breath Sounds

    Listen for normal breath sounds

    • If bronchovesicular or bronchial breath sounds are heard in locations where vesicular breath sounds are expected, suspect that air filled lung has been replaced by fluid filled or solid lung tissue

    Vesicular (soft)
    Duration: Longer in inspiration
    Location: Most of the lungs

    Brochovesicular (medium intensity)
    Duration: Equal in inspiration and expiration
    Location: 1st and 2nd intercostal spaces anteriorly, interscapular area posteriorly

    Bronchial (loud)
    Duration: Longer in expiration, silent gap between inspiration and expiration
    Location: Most of the lungs

    Tracheal (very loud)
    Duration: Equal in inspiration and expiration, silent gap
    Location: Trachea

    Adventitious Breath Sounds

    • Assess location and timing in respiratory cycle (inspiration vs expiration) and whether they clear with cough
      • Basilar atelectasis may clear with a cough
    • Discontinuous: intermittent, non-musical)
      • Crackles/rales:
        • Fine, soft, high-pitched, very brief

      • Rales:
        • Coarse: louder, lower in pitch

    • Continuous: Musical, prolonged
      • Wheezes: relatively high-pitched hissing/shrill quality
        • Suggestive of lower airway obstruction
      • Rhonchi: low-pitched with snoring quality on expiration. Can usually clear with cough. This denotes secretions in the airways

      • Stridor: high pitched harsh sound on inspiration, usually denoting upper airway obstruction (eg. foreign body)
    • Voice Resonance

    References

    1. Bickley LS. The thorax and lungs. In: Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:283-321.
    2. McGee SR. The Lungs. In: McGee SR, EBM Evidence Based Physical Diagnosis. 2nd ed. St. Louis, MO: Saunders; 2007:303-348.
    3. Crump HW. Pectus excavatum. American Family Physician. 1992;46(1):173-179
    4. Lincolin M, McSheffrey G, Tran C, Wong D. In: Essentials of Clinical Examination Handbook. 6th ed. Toronto, ON: The Medical Society Faculty of Medicine, University of Toronto; 2010:335-351