General Observation

Much information can be gleaned from a good hard look at the patient. You should have a mental checklist of questions and a systematised survey as there is a lot of information to be gathered.

What is the general appearance? Are they well or unwell, cachectic from malignancy or severe COPD, or are they obese?

Observe the respiration. Carefully count the respiratory rate. Normal is 12 to 16 breaths per minute. Tachypnoea may occur as a result of breathlessness or secondary to a metabolic acidosis. Is the respiratory rhythm abnormal? For example Cheyne–Stokes respiration is associated with cardiac failure.
How hard are they working to breathe? Increased work of breathing is an important prognostic sign in both acute and chronic respiratory conditions and is closely related to the perception of dyspnoea. Look to see if the patient is using accessory respiratory muscles, such as the sternocleidomastoids and platysma muscles of the neck. Use of these muscles may be particularly prominent in those with severe airflow obstruction and hyperinflation of the chest.. Intercostal recession of the lower chest is also suggestive of hyperinflation as, in this state, the diaphragm is away from the chest wall thus exposing the lower intercostal regions to intrathoracic instead of intra-abdominal pressures.

Take time to assess the shape and symmetry of the thoracic cavity. Significant hyperinflation is a feature of severe COPD and may result in an increased anteroposterior diameter of the chest or “barrel chest”. This is best appreciated by observing the patient from above whilst they are sitting. The AP diameter will often approach the lateral diameter. Identification of a barrel chest has only 10% sensitivity (taken in isolation) for predicting airflow obstruction but over 90% specificity1. Restrictive chest wall disease may arise from distortion of the spine, ribs or sternum. Kyphosis and scoliosis are common, especially in the elderly. Asymmetry may also result from any process resulting in loss of lung volume, from lobar collapse to pneumonectomy. In the past radical surgery was performed for patients with tuberculosis, this approach involved procedures that lead to pleural scarring and lung collapse, the result of which led to dramtatic alteration of shape to the thoracic cavity. Over many years this may result in marked deformity which may lead to severe physiological restriction. Also note the muscle bulk as marked wasting may suggest a neuropathic or myopathic process that may lead to weakness of the muscles of respiration. Are there any surgical scars from thoracotomy, thoracoscopy or intercostal catheter insertion?

Ask the patient to cough a few times. Note whether the cough is dry or loose and productive. Is it strong and effective or weak and ineffectual? Inspect the contents of a sputum cup if present. A hoarse voice and a “bovine cough” are suggestive of vocal cord paralysis.

Forced expiratory time (FET) is a manoeuvre where the patient is asked to sit upright, to maximally inhale and then to exhale through an open mouth as forcefully as possible. The clinician listens over the trachea in the suprasternal notch. Obstructive airways disease is associated with a longer expiratory time, up to 20 seconds. Expiration time of greater than 9 seconds was highly predictive of airflow obstruction (FEV1/FVC < 70%).
Taken together with wheeze during tidal breathing, prolonged FET >9 seconds is highly predictive of airflow obstruction.
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