Trying to raise my kids the best I can

Monday, June 22, 2009

Respiratory exams

I'm kind of putting this here for my own use- so I can easily look this back up when I need it.

It's a really thorough description of how to perform respiratory exams on the elderly that I got from Medscape. I think this information will be really critical in the coming flu season.

The objective of the pulmonary assessment of a geriatric patient is to check for the following:

  • Quality of respiratory efficiency;
  • Gas exchange; and
  • Presence of disease.

Assessing Respiration Efficiency

Of note, if the patient is bedfast, complete evaluation of respiratory efficiency is often less than optimal because chest expansion is not always symmetric and percussion notes may be less resonant.

Respiratory Rate

Although a patient's respiratory rate is often recorded in his or her chart (most often as 20 breaths per minute), cultivate the discipline to obtain it yourself. Count the respirations for a minute and observe the pattern and degree of respiratory effort. Note that moving the diaphragm without moving any air does not count as a breath. Normal respiratory rates for older patients are12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care.

Tachypnea. A respiratory rate of 20 breaths per minute (or more than 25 breaths per minute for someone in a nursing home) indicates tachypnea. In such cases, look for the following:

  • Infection (especially pneumonia);
  • Reactive airways disease (eg, in acute exacerbations of chronic obstructive pulmonary disease [COPD], the patient has air trapping and cannot empty the lungs);
  • Congestive heart failure (patient pants in midrespiration);
  • Pulmonary embolus (very few elderly patients with pulmonary embolus have respiratory rates less than 16); and
  • Metabolic acidosis.

A respiratory rate of more than 30 breaths per minute in a patient with suspected abdominal disease suggests primary chest disease with referred symptoms to the abdomen.

Bradypnea. Bradypnea is a form of hypoventilation, in which the patient has a respiratory rate of less than 10 breaths per minute. In such cases, you might suspect severe myxedema, ingestion of central nervous system (CNS) depressants (eg, narcotics, benzodiazepines), or CNS disease (pontine hemorrhage, hypoglycemia, meningitis).

Respiratory Effort

Normal breathing is quiet and unlabored. If it is labored, it is important to note respiratory effort. In patients with pneumonia or acute abdomen, labored breathing prevents airway closure. Patients who have air hunger will often breathe with an open mouth. Pursed lip breathing mainly in expiration is seen in end-stage emphysema and suggests small-airway disease with terminal bronchiole collapse. Expiring with pursed lips increases the end-expiratory pressure, keeping the airways open and reducing the work of breathing. (It takes more work to put the first breath into a balloon than to add a breath to an already half-filled balloon.)

Audible Breath Sounds

Pay attention to the breath sounds. Wheezing, a musical sound, is an important clue to reactive airways or local obstruction. Coughing indicates lower airway irritation. Stridor (a high-pitched shrieking sound) implies partial airway obstruction. Expiratory stridor without inspiratory stridor suggests lower airway obstruction. Stridor on inspiration and expiration implies airway obstruction at the glottis. Of note, inspiratory stridor suggests obstruction in the oral airway or epiglottis and is a medical emergency.

Respiratory Patterns

Check for respiratory patterns and signs that indicate specific conditions. For example, inspiration interrupted by cough suggests pleuritic pain or inflammation. The following are other patterns and signs to look for.

Kussmaul's Respiration. Kussmaul's respiration is deep rapid respiration (an exaggeration of normal) in metabolic acidosis and is classically associated with diabetic ketoacidosis. Patients with Kussmaul's respiration may have an increase in tidal volume. While talking, they need to breathe between phrases, so their speech pattern can seem choppy.

Cheyne-Stokes Respiration. The pattern of Cheyne-Stokes respiration is one of increasingly deep respirations followed by a steady diminution of breathing until an apneic episode occurs, which can signify prolonged circulatory time or primary neurologic disease. Among the differential diagnoses are the following:

  • Primary CNS disease;
  • Chronic heart failure, meningitis;
  • Pneumonia;
  • Carbon monoxide poisoning; and
  • Medications (eg, morphine).

Obesity may be present. Some patients will show pupillary dilation with rapid breathing and pupillary contraction with apnea.

Biot's Breathing. Biot's breathing is characterized by irregular breathing (the "atrial fibrillation" of respiration) with sudden apneas. It suggests CNS disease and can be a sign of increased intracranial pressure or meningitis.

Apneustic Breathing. Apneustic breathing is seen in severely ill patients with coma. The patient holds his or her breath at the end of inspiration until the Hering-Breuer (carotid body) reflex initiates exhalation. This breathing pattern suggests pontine disease.

1 Comments:

  • At 11:04 PM, Blogger Anne Basso said…

    Great post! Let me offer a piece of practical advice too, if I may. Working in a TCU setting, I evaluate respiratory function in the elderly quite frequently.

    I've found that younger patients are so much easier to evaluate. They take good strong breaths and different sounds are easy to make out.

    In the elderly, especially if they're weak or sick, they're respiratory function may be less than optimal. They're breaths are weak and tough to auscultate. I always note it if breath sounds are diminished. And I still have to remember to trust myself.

    The other day I had an 88 year old gentleman who I thought I heard crackles in his right lower lobe during his admission assessment. But his breath sounds were diminished bilaterally, and then he coughed a bit and I just couldn't be sure that it wasn't a little bronchial congestion that I'd heard. I looked in his chart and sure enough, he had a dx of pneumonia with a right lower lobe infiltrate. Even after 8 years of doing this job, I still have to remember that I know what I'm doing!

    This really is great info and I hope you'll post more like it. It's a good refresher. =)

     

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