Breathlessness

Breathlessness is the subjective awareness of an increased work of breathing. It is the predominant symptom of both cardiac and respiratory disease. It also occurs in anaemia where the oxygen-carrying capacity of the blood is reduced, in neuromuscular disorders where the respiratory muscles are affected, and in metabolic disorders where there is a change in the acid–base equilibrium (Chapter 3) or metabolic rate (e.g. hyperthyroid disorders). Breathlessness is also found in hyperventilation syndrome or dysfunctional breathing where psychological factors (e.g. anxiety) may be contributory factors.

The pathophysiological mechanisms causing breathlessness are still the subject of intensive investigation. Many factors are involved, including respiratory muscle length–tension relationships, respiratory muscle fatigue, stimulation of pulmonary stretch receptors, and alterations in central respiratory drive.

The duration and severity of breathlessness is most easily assessed through enquiries about the level of functioning in the recent and distant past. For example, a patient may say that 3 years ago he could walk up five flights of stairs without stopping, but now cannot manage even one flight. Some patients may deny breathlessness as they have (unconsciously) decreased their activity levels so that they do not get breathless. They may acknowledge breathlessness only when it interferes with important activities, e.g. bathing. The physio-therapist should always relate breathlessness to the level of function that the patient can achieve.

Comparison of the severity of breathlessness between patients is difficult because of differences in perception and expectations. To overcome these difficulties, numerous gradings have been proposed. The New York Heart Association classification of breathlessness, shown in Box 1.1, was developed for patients with cardiac disease, but is also applicable to respiratory patients. The Borg Rating of Perceived Exertion Scale (Borg 1982) is another scale that is frequently used for both respiratory and cardiac patients. No scale is universal and it is important that all staff within one institution use the same scale.

Breathlessness is usually worse during exercise and better with rest. An exception is hyperventilation syndrome where breathlessness may improve with exercise. Two patterns of breathlessness have been given specific names:

Orthopnoea is breathlessness when lying flat

Paroxysmal nocturnal dyspnoea (PND) is breathlessness that wakes the patient at night.

In the cardiac patient, lying flat increases venous return from the legs so that blood pools in the lungs, causing breathlessness. A similar pattern may be described in patients with severe asthma, but here the breathlessness is caused by nocturnal bronchoconstriction.

Further insight into a patient’s breathlessness may be gained by enquiring about precipitating and relieving factors. Breathlessness associated with exposure to allergens and relieved by bronchodilators is typically found in asthma.

Cough

Coughing is a protective reflex that rids the airways of secretions or foreign bodies. Any stimulation of receptors located in the pharynx, larynx, trachea or bronchi may induce cough. Cough is a difficult symptom to clarify as most people cough normally every day, yet a repetitive persistent cough is both troublesome and distressing. Smokers may discount their early morning cough as being ‘normal’ when in fact it signifies chronic bronchitis.

Important features concerning cough are its effectiveness, and whether it is productive or dry. The severity of cough may range from an occasional disturbance to continual trouble. A loud, barking cough, which is often termed ‘bovine’, may signify laryngeal or tracheal disease. Recurrent coughing after eating or drinking is an important symptom of aspiration. A chronic productive cough every day is a fundamental feature of chronic bronchitis and bronchiectasis. Interstitial lung disease is characterized by a persistent, dry cough. Nocturnal cough is an important symptom of asthma in children and young adults, but in older patients it is more commonly due to cardiac failure. Drugs, especially beta-blockers and some other antihypertensive agents, can cause a chronic cough. Chronic cough may cause fractured ribs (cough fractures) and hernias. Stress incontinence is a common complication of chronic cough, especially in women. As this subject is often embarrassing to the patient, specific questioning may be required (see below).

Postoperatively, the strength and effectiveness of cough is important for the physiotherapist to assess.

Sputum

In a normal adult, up to 100 ml of tracheobronchial secretions are produced daily and cleared subconsciously by swallowing. Sputum is the excess tracheobronchial secretions that are cleared from the airways by coughing or huffing. It may contain mucus, cellular debris, microorganisms, blood and foreign particles. Questioning should determine the colour, consistency and quantity of sputum produced each day. This may clarify the diagnosis and the severity of disease (Table 1.1).

Table 1.1 Sputum analysis

A number of grading systems for mucoid, mucopurulent, purulent sputum have been proposed. For example, Miller (1963) suggested:

However, in clinical practice sputum is often classified as mucoid, mucopurulent or purulent, together with an estimation of the volume (1 teaspoon, 1 egg cup, half a cup, 1 cup). Odour emanating from sputum signifies infection. In general, particularly offensive odours suggest infection with anaerobic organisms (e.g. aspiration pneumonia, lung abscess).

In patients with allergic bronchopulmonary aspergillosis (ABPA), asthma and occasionally bronchiectasis, sputum ‘casts’ may be expectorated. Classically these take the shape of the bronchial tree.

Haemoptysis is the presence of blood in the sputum. It may range from slight streaking of the sputum to frank blood. Frank haemoptysis can be life threatening, requiring bronchial artery embolization or surgery. Isolated haemoptysis may be the first sign of bronchogenic carcinoma, even when the chest radiograph is normal. Patients with chronic infective lung disease often suffer from recurrent haemoptyses.

Wheeze

Wheeze is a whistling or musical sound produced by turbulent airflow through narrowed airways. These sounds are generally noted by patients when audible at the mouth. Stridor, the sound of an upper airway obstruction, is often mistakenly called ‘wheeze’ by patients. Heart failure may also cause wheezing in those patients with significant mucosal oedema. Wheezing is discussed in more detail later in this chapter.

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 is caused by inflammation of the parietal pleura, and is usually described as a severe, sharp, stabbing pain that 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 is a major symptom of cardiac disease. Myocardial ischaemia characteristically causes a dull central retrosternal gripping or band-like sensation, which may radiate to either arm, neck or jaw.

Pericarditis may cause pain similar to angina or pleurisy.

A differential diagnosis of chest pain is given in Table 1.2.

Table 1.2 Syndromes of chest pain

Incontinence

Incontinence is a problem that is often aggravated by chronic cough (Orr et al 2001, Scottish Intercollegiate Guidelines Network 2004, Thakar & Stanton 2000). Coughing and huffing increase intra-abdominal pressure, which may precipitate urine leakage. Fear of this may influence compliance with physiotherapy. Thus, identification and treatment of incontinence is important. Questions may need to be specific to elicit this symptom: ‘When you cough, do you find that you leak some urine? ‘Does this interfere with your physiotherapy?’

Other symptoms

Of the other symptoms a patient may report, a number have particular importance:

Fever (pyrexia) is one of the common features of infection, but low-grade fevers can also occur with malignancy and connective tissue disorders. Equally, infection may occur without fever, especially in immunosuppressed (e.g. chemotherapy) patients or those on corticosteroids. High fevers occurring at night, with associated sweating (night sweats), may be the first indicator of pulmonary tuberculosis.

Headache is an uncommon feature of respiratory disease. Morning headaches in patients with severe respiratory failure may signify nocturnal carbon dioxide retention. Early morning arterial blood gases or nocturnal transcutaneous carbon dioxide monitoring are required for confirmation.

Peripheral oedema in the respiratory patient suggests right heart failure, which may be due to cor pulmonale (right ventricular failure secondary to hypoxic pulmonary vasoconstriction). Peripheral oedema may also occur in patients taking high-dose corticosteroids, as a result of salt and water retention.

Functional ability

It is important to assess the patient as a whole, enquiring about their daily activities. If the patient is employed, what does the job actually entail? For example, a surveyor may sit behind a desk all day, or may be climbing 25-storey buildings. The home situation should also be documented, in particular the number of stairs to the front door and within the house. With whom does the patient live? What roles does the patient perform in the home (shopping, housework, cooking)? Finally, questions concerning activities and recreation often reveal areas where significant improvements in quality of life can be made.

Quality of life

Assessment of quality of life (QOL) is becoming increasingly important to assess the impact of disability on the patient and as a measure of response to treatment. QOL scales measure the effect of an illness and its management upon a patient as perceived by the patient. Often there is little correlation between physiological measures (e.g. lung function) and QOL. A number of both generic, for example SF-36 (Ware & Sherbourne 1992) and disease-specific QOL scales are available which allow data to be gathered principally by self-report questionnaires or interview. QOL scales available for assessment of patients with respiratory or cardiovascular disease are reviewed elsewhere (Juniper et al 1999, Kinney et al 1996, Mahler 2000, Pashkow et al 1995). The choice of a QOL measure requires an evaluation of QOL scales with respect to their reliability, validity, responsiveness and appropriateness (Aaronson 1989).

Disease awareness

During the interview it is important to ascertain the patient’s knowledge of his disease and treatment. The level of compliance with treatment, often difficult to assess initially, may become evident as rapport develops. These issues will influence the goals of treatment.

General observation

Examination starts by observing the patient from the end of the bed. Is the patient short of breath, sitting on the edge of the bed, distressed? Is he obviously cyanosed? Is he on supplemental oxygen? If so, how much? What is the speech pattern – long fluent paragraphs without discernible pauses for breath, quick sentences, just a few words, or are they too breathless to speak? When he moves around or undresses, does he become distressed? With a little practice, these observations should become second nature and can be noted while introducing yourself to the patient.

In the intensive care patient there are a number of further features to be observed. The level of ventilatory support must be ascertained. This includes both the mode of ventilation (e.g. supplemental oxygen, continuous positive airway pressure, intermittent positive pressure ventilation) and the route of ventilation (mask, endotracheal tube, tracheostomy). The level of cardiovascular support should also be noted, including drugs to control blood pressure and cardiac output, pacemakers and other mechanical devices. The patient’s level of consciousness should also be noted. Any patient with a decreased level of consciousness is at risk of aspiration and retention of pulmonary secretions. In those patients who are not pharmacologically sedated, the level of consciousness is often measured using the Glasgow Coma Scale (Box 1.2). This gives the patient a score (from 3 to 15) based on his best motor, verbal and eye responses.

The patient’s chart should then be examined for recordings of temperature, pulse, blood pressure and respiratory rate. These measurements are usually performed by the nursing staff immediately on admission of the patient and regularly thereafter.

Intercostal drains are placed between two ribs into the pleural space to remove air, fluid or pus which has accumulated. They are also used routinely after cardiothoracic surgery. In general, the tube is attached to a bottle partially filled with sterile water, called an ‘underwater seal drain’ (Chapter 11). The bottle should be positioned at least 0.5 metres below the patient’s chest (usually on the floor). Bubbling indicates that air is entering the tube from the pleural space at that time. Frequent observations must be made of the fluid level within the tube, which should oscillate or ‘swing’ with every breath. If the fluid does not swing, the tube is not patent and requires medical attention. In certain situations the bottle may be connected to continuous suction, which will dampen the fluid ‘swing’. Those patients who are producing large volumes of fluid or pus may be connected to a double bottle system, where the first bottle acts as a reservoir to collect the fluid and the second provides the underwater seal. Fully enclosed disposable plastic systems are now available. Any patient with a chest drain should have a pair of large forceps available at all times to clamp the tube if any connection becomes loosened.

The hands.

Significant findings can be identified by observing and examining the hands. A fine tremor will often be seen in association with high-dose bronchodilators. Warm and sweaty hands with an irregular flapping tremor may be due to acute carbon dioxide retention. Weakness and wasting of the small muscles in the hands may be an early sign of an upper lobe tumour involving the brachial plexus (Pancoast’s tumour). Examination of the fingers may show nicotine staining from smoking.

Clubbing is the term used to describe the changes in the fingers and toes as shown in Figure 1.2. The first sign of clubbing is the loss of the angle between the nail bed and the nail itself. Later, the finger pad becomes enlarged. The nail bed may also become ‘spongy’, but this is a difficult sign to elicit. A summary of the diseases associated with clubbing is given in Box 1.3. The exact cause of clubbing is unknown. It is interesting to note that clubbing in cystic fibrosis patients disappears after heart and lung or lung transplant.

Figure 1.2 Clubbing: (A) normal; (B) early clubbing; (C) advanced clubbing.

Box 1.3 Causes of clubbing

Lung disease	Infective (bronchiectasis, lung abscess, empyema) Fibrotic Malignant (bronchogenic cancer, mesothelioma)
Cardiac disease	Congenital cyanotic heart disease Bacterial endocarditis
Other	Familial Cirrhosis Gastrointestinal disease (Crohn’s disease, ulcerative colitis, coeliac disease)

Observation of the chest

When examining the chest it is important to remember the surface landmarks of the thoracic contents (Fig. 1.3). Some important points are:

Figure 1.3 Surface markings of the lungs: H, horizontal fissure; O, oblique fissure; RUL, right upper lobe; LUL, left upper lobe; RML, right middle lobe; LLL, left lower lobe; RLL, right lower lobe.

The oblique fissure, dividing the upper and middle lobes from the lower lobes, runs underneath a line drawn from the spinous process of T2 around the chest to the sixth costochondral junction anteriorly.

The horizontal fissure on the right, dividing the upper lobe from the middle lobe, runs from the fourth intercostal space at the right sternal edge horizontally to the midaxillary line, where it joins the oblique fissure.

The diaphragm sits at approximately the sixth rib anteriorly, the eighth rib in the midaxillary line and the 10th rib posteriorly.

The trachea bifurcates just below the level of the manubriosternal junction.

The apical segment of both upper lobes extends 2.5 cm above the clavicles.

Chest shape.

The chest should be symmetrical with the ribs, in adults, descending at approximately 45° from the spine. The transverse diameter should be greater than the anteroposterior (AP) diameter. The thoracic spine should have a slight kyphosis. Important common abnormalities include:

kyphosis, where the normal flexion of the thoracic spine is increased

kyphoscoliosis, which comprises both lateral curvature of the spine with vertebral rotation (scoliosis) and an element of kyphosis. This causes a restrictive lung defect which, when severe, may cause respiratory failure

pectus excavatum, or ‘funnel’ chest, is where part of the sternum is depressed inwards. This rarely causes significant changes in lung function but may be corrected surgically for cosmetic reasons

pectus carinatum, or ‘pigeon’ chest, is where the sternum protrudes anteriorly. This may be present in children with severe asthma and rarely causes significant lung function abnormalities

hyperinflation, where the ribs lose their normal 45° angle with the thoracic spine and become almost horizontal. The anteroposterior diameter of the chest increases to almost equal the transverse diameter. This is commonly seen in severe emphysema.

Chest movement.

During normal inspiration, there are symmetrical increases in the anteroposterior, transverse and vertical diameters of the chest. The increase in vertical diameter is achieved by contraction of the diaphragm, causing the abdominal contents to descend. Sternal and rib movements are responsible for the increases in anteroposterior and transverse diameters of the chest. These movements can be divided into two components (Fig. 1.4). When elevated, the anterior ends of the ribs move forward and upwards with anterior movement of the sternum. This increase in anteroposterior diameter is likened to the movement of an old fashioned ‘pump handle’. At the same time, rotation of the ribs causes an increase in the transverse diameter, likened to the movement of a ‘bucket handle’.

Figure 1.4 Chest wall movement.

During normal quiet breathing, the diaphragm is the main inspiratory muscle increasing the vertical diameter. There is also an increase in the lower thoracic transverse diameter due to external intercostal muscle contraction. Expiration is passive, caused by the elastic recoil of the lung and chest wall. When breathing is increased, all the accessory inspiratory muscles (sternomastoid, scalenes, trapezii) contract to increase the anteroposterior and transverse diameters, and the diaphragm activity increases, thus further increasing the vertical dimensions. Expiration may become active with contraction of the abdominal and internal intercostal muscles.

Intercostal indrawing occurs where the skin between the ribs is drawn inwards during inspiration. It may be seen in patients with severe inspiratory airflow resistance. Larger negative pressures during inspiration suck the soft tissues inwards. This is an important sign of respiratory distress in children, but is less often seen in adults.

Palpation of the chest

Chest expansion.

This can be assessed by observation, but palpation is more accurate. The patient is instructed to expire slowly to residual volume. At residual volume the examiner’s hands are placed spanning the posterolateral segments of both bases, with the thumbs touching in the midline posteriorly, as shown in Figure 1.5. In obese patients, it helps if the skin of the anterior chest wall is slightly retracted by the fingertips. The patient is then instructed to inspire slowly and the movement of both thumbs is observed. Both sides should move equally, with 3–5 cm being the normal displacement.

Figure 1.5 Palpation of thoracic expansion.

A similar technique may be used anteriorly, again to measure basal movements. Measurement of apical movement is more difficult. By placing the hand over the upper chest anteriorly, a qualitative comparison of the two sides can be made. In all cases, diminished movement is abnormal.

Paradoxical breathing is where some or all of the chest wall moves inwards on inspiration and outwards on expiration. It can involve anything from a localized area to the entire chest wall. Localized paradox occurs when the integrity of the chest wall is disrupted. Fractures of multiple ribs with two or more breaks in each rib will result in the central section losing the support usually provided by the rest of the thoracic cage. Thus, during inspiration, this loose segment (often called a ‘flail segment’) is drawn inwards as the rest of the chest wall moves out. In expiration the reverse occurs.

Paradoxical movement of one hemithorax may be remarkably difficult to observe. It may be caused by unilateral diaphragm paralysis. Paradox of the entire chest wall occurs in bilateral diaphragm weakness or paralysis. It is most apparent when the patient is supine.

Paradoxical movement of the lower chest can occur in patients with severe chronic airflow limitation who are extremely hyperinflated. As the dome of the diaphragm cannot descend any further, diaphragm contraction during inspiration pulls the lower ribs inwards. This is called ‘Hoover’s sign’.

Percussion

Percussion of the chest provides further information that can help in the assessment and localization of lung disease. It is performed by placing the left hand firmly on the chest wall so that the fingers have good contact with the skin. The middle finger of the left hand is struck over the distal interphalangeal joint with the middle finger of the right hand. The right wrist should be relaxed so that the weight of the entire right hand is transmitted through the middle finger. Both sides of the chest from top to bottom should be percussed alternately, paying particular attention to the comparison between sides.

Resonance is generated by the chest wall vibrating over the underlying tissues. Normal resonance is heard over aerated lung, while consolidated lung sounds dull, and a pleural effusion sounds ‘stony dull’. Increased resonance is heard when the chest wall is free to vibrate over an air-filled space, such as a pneumothorax or bulla. In situations where the chest wall is unable to move freely, as may occur in obese patients, the percussion note may sound dull, even if the underlying lung is normal.

Auscultation

Chest auscultation is the process of listening to and interpreting the sounds produced within the thorax. A stethoscope simplifies auscultation and facilitates localization of any abnormalities. It consists of a diaphragm and bell connected by tubing to two earpieces. The diaphragm is generally used for listening to breath sounds, while the bell is best for the very low frequencies generated by the heart (especially the third and fourth heart sounds). The diaphragm and bell must be intact for a sound to be heard properly, and the tubing relatively short to minimize absorption of the sound. The earpieces, made of plastic or rubber, should fit snugly within the ears, pointing slightly forward in order to maximize sound transmission into the auditory canal.

A teaching stethoscope (Fig. 1.6) is a useful tool to allow both the experienced and inexperienced physiotherapist to hear the same sounds simultaneously (Ellis 1985). More recently, a number of electronic stethoscopes have been produced, allowing teacher and students to listen together.

Figure 1.6 A Littmann teaching stethoscope.

Chest auscultation should ideally be performed in a quiet room, with the chest exposed. The patient is instructed to take deep breaths through an open mouth, as turbulence within the nose can interfere with the breath sounds. There is a wide variation in the intensity of breath sounds depending on chest wall thickness. The terms used are described below.

Breath sounds

Normal breath sounds are generated by turbulent airflow in the trachea and large airways. These sounds, which can be heard directly over the trachea, comprise high, medium and low frequencies. The higher frequencies are attenuated by normal lung tissue so that breath sounds heard over the periphery are softer and lower pitched. Originally it was thought that the higher-pitched sounds were generated by the bronchi (bronchial breath sounds) and the lower ones by airflow into the alveoli (vesicular breath sounds). It is now known that normal breath sounds (previously called ‘vesicular’) simply represent filtering of the ‘bronchial’ breath sounds generated in the large airways. Although technically incorrect, normal breath sounds are still sometimes referred to as ‘vesicular’ or ‘bronchovesicular’. Normal breath sounds are heard all over the chest wall throughout inspiration and for a short period during expiration.

Bronchial breath sounds are the normal tracheal and large airway sounds, transmitted through airless lung, which does not attenuate the higher frequencies. Thus, the sounds heard over an area of consolidated lung are similar to those heard over the trachea itself. Bronchial breath sounds are loud and high-pitched, with a harsh quality. They are heard equally throughout inspiration and expiration, with a short pause between the two. In all three respects, bronchial breath sounds differ from normal breath sounds which are faint, lower-pitched and absent during the latter half of expiration.

If the bronchus supplying an area of consolidated lung is obstructed (e.g. carcinoma, large sputum plug) bronchial breath sounds may not be heard as the obstruction blocks sound transmission.

Diminished sounds occur when there is a reduction in the initial generation of the sound or when there is an increase in sound attenuation. As the breath sounds are generated by flow-related turbulence, reduced flow causes less sound. Thus patients who will not (e.g. due to pain) or cannot (e.g. due to muscle weakness) breathe deeply will have globally diminished breath sounds. Similarly, diminished breath sounds are heard in some patients with emphysema where the combination of parenchymal destruction and hyperinflation causes greater attenuation of the normal breath sounds. In obese patients, breath sounds are diminished by attenuation through the fat over the chest wall.

Locally diminished breath sounds may represent obstruction of a bronchus by tumour or large sputum plugs. Localized accumulation of air or fluid in the pleural space will block sound transmission so that breath sounds are absent.

Added sounds

Wheezes, previously called ‘rhonchi’, are musical tones produced by airflow vibrating a narrowed or compressed airway. A fixed, monophonic wheeze is caused by a single obstructed airway, while polyphonic wheezes are due to widespread disease. Any cause of narrowing, for example, bronchospasm, mucosal oedema, sputum or foreign bodies, may cause wheezes. As the airways are normally compressed during expiration, wheezes are first heard at this time. When airway narrowing is more severe, wheezes may also be heard during inspiration. The pitch of the wheeze is directly related to the degree of narrowing, with high-pitched wheezes indicating near total obstruction. However, the volume of the wheeze may be misleading as the moderate asthmatic may have loud wheezes while the very severe asthmatic may have a ‘quiet chest’ because he is not generating sufficient airflow to cause wheezes.

Low-pitched, localized wheezes are caused by sputum retention and can change or clear after coughing.

Crackles, previously called ‘crepitations’ or ‘râles’, are clicking sounds heard during inspiration. They are caused by the opening of previously closed alveoli and small airways during inspiration. Crackles are described as ‘early’ or ‘late’, ‘fine’ or ‘coarse’, and ‘localized’ or ‘widespread’. Coarse, early inspiratory crackles occur when bronchioles open (often heard in bronchiectasis and bronchitis), while fine, late inspiratory crackles occur when alveoli and respiratory bronchioles open (often heard in pulmonary oedema and pulmonary fibrosis). When severe, the late inspiratory crackles of pulmonary oedema and pulmonary fibrosis may become coarser and start earlier in inspiration.

Localized crackles may occur in dependent alveoli, which are gradually closed by compression from the lung above. This early feature of subsegmental lung collapse resolves when the patient breathes deeply or coughs. The crackles of pulmonary oedema are also more marked basally, but only clear transiently after coughing. The differentiation between subsegmental lung collapse and pulmonary oedema may be difficult, and sometimes auscultation will not clarify the situation. Elevation of the jugular venous pressure and peripheral oedema suggest pulmonary oedema, whereas ineffective cough, recent anaesthesia and pyrexia suggest sputum retention, which could lead to subsegmental lung collapse (Table 1.3). Postoperative and intensive care patients may have a combination of both pulmonary oedema and sputum retention.

Table 1.3 Differentiation between pulmonary oedema and sputum retention

JVP, jugular venous pressure

Pleural rub is the creaking or rubbing sound that occurs with each breath when the pleural surfaces are roughened by inflammation, infection or neoplasm. Normally the visceral and parietal pleura slide silently. Pleural rubs range from being localized and soft to being loud and generalized, sometimes even palpable. In certain instances, they may be difficult to differentiate from crackles. An important distinguishing feature is that pleural rubs are heard equally during inspiration and expiration, with the sounds often recurring in reverse order during expiration.

Vocal resonance.

Vocal resonance is the transmission of voice through the airways and lung tissue to the chest wall where it is heard through a stethoscope. It is usually tested by instructing the patient to say ‘ninety-nine’ repeatedly (like vocal fremitus which is felt with the hands). As mentioned previously, normal lung attenuates the higher frequencies so that the lower frequencies dominate. Thus, speech normally becomes a low-pitched mumble. Consolidated lung transmits all sounds better, especially the high frequencies, so the transmitted sound is louder and higher pitched. In this situation speech can actually be understood. Whispered speech lacks the lower frequencies and is normally not transmitted to the chest wall. However, over areas of consolidation the whisper is clearly heard and intelligible – this is called ‘whispering pectoriloquy’.

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As with auscultation of breath sounds, vocal resonance is decreased when the transmission of sound through the lung or from the lung to chest wall is impeded. This occurs with emphysema, pneumothorax, pleural thickening or pleural effusion.

A summary of the chest examination in selected chest problems is given in Table 1.4.

Table 1.4 Summary of chest examination in selected chest problems

Sputum

At the end of the respiratory examination, it is often worthwhile to instruct the patient to huff to a low lung volume to assess the presence of retained secretions. Any sputum produced should be examined for colour, consistency and quantity as previously described.

Physiotherapy techniques

In patients who have previously been taught physiotherapy, it is important to ascertain which techniques are used, how well they are performed, and their effectiveness. For example, patients who use huffing to clear retained secretions should have its effectiveness assessed. Suboptimal techniques need to be identified and their correction included in the treatment plan.

Exercise capacity

For a complete assessment of the respiratory system, exercise capacity should also be measured. Depending on the situation, this may vary from a full exercise test for measuring maximum oxygen uptake, to a simple assessment of breathlessness during normal activities. An exercise test provides the best measure of functional limitation, which may differ from that suggested by a patient’s lung function. Two of the most common methods used to assess patients with respiratory disease are the 6-minute walking test (Butland et al 1982) and the shuttle walking tests (Bradley et al 1999, Revill et al 1999, Singh et al 1992).

Spirometry

The forced expiratory volume in 1 second (FEV₁), the forced vital capacity (FVC) and peak expiratory flow (PEF) are important measures of ventilatory function. Normal values, based on population studies, depend on age, height, sex and race. Weight is not an important determinant of lung function, except in the markedly obese or malnourished.

Although often expressed as absolute values, lung function should always be compared with predicted values and previous recordings for that patient. For example a 21-year-old, 6-foot-tall male asthmatic changing his spirometry (FEV₁/FVC) from 4.0/5.0 litres to 1.5/3.0 litres should cause concern, while a normal 81-year-old, 5-foot female may never manage to blow more than 1.3/1.8 litres!

Arterial blood gases

Arterial blood gases (ABGs) provide an accurate measure of oxygen uptake and carbon dioxide removal by the respiratory system as a whole. The arterial blood is usually sampled from the radial artery at the wrist, but arterialized capillary samples may be taken from the earlobe. Arterial blood gases are best used as a mea-sure of steady-state gas exchange; thus it is imperative that the patient is resting quietly with a constant inspired oxygen level (FiO₂) and mode of ventilation for at least 30 minutes before sampling. When analysing the results, consideration must be given to all these factors. Normal values for arterial blood gases are given in Box 1.4.

Thoracic imaging

Chest radiographs and other imaging techniques (Chapter 2) are an important aid to physical examination as they provide a clear picture of the extent and severity of disease at that time. In some instances, chest radiographs or computed tomography (CT) may show more extensive disease than expected, while in others they may underestimate the pathology present. Comparison with previous images provides an excellent measure of improvement or deterioration over time, and an objective assessment of the response to treatment. It should be noted that chest radiograph may sometimes lag 1–2 days behind the clinical findings.

Electrocardiogram and echocardiograms

The electrocardiogram (ECG) and echocardiogram provide important information regarding cardiac electrical and mechanical function. An understanding of these is essential as abnormalities may alter the treatment plan. More detailed information about their measurement and implications are covered in Chapter 3.

Outcomes

The short- and long-term goals provide a basis for evaluating the effectiveness of treatment for each problem. One of the best indicators of outcome is the change in objective findings after treatment. Although changes that occur immediately after a single treatment are related to physiotherapy intervention alone, changes over longer periods of time reflect treatment by the entire health team. Chest auscultation before and after a treatment may provide a simple indication of the effectiveness of that treatment. Similarly, the chest radiograph can demonstrate the effectiveness of physiotherapy treatment by showing diminution in the area of collapsed/consolidated lung. On a long-term basis, changes in lung function or exercise tolerance provide the most valuable measures of treatment outcome. If there are discrepancies between the actual and expected outcomes, the plan (P) documents the changes to the goals and/or treatment, as required.

The selection and use of appropriate outcome measures is fundamental to the evaluation of any therapy. Demonstrating the effects of physiotherapy intervention, using instruments that have high reliability and validity, is increasingly being required by healthcare providers and physiotherapists themselves. Other people who may require outcome data include the patient, caregivers, community and patient support groups.

To standardize the measurement of outcomes, the World Health Organization (WHO) has developed a scale of functioning and disability, the International Classification of Functioning, Disability and Health (ICIDH-2) (WHO 2001). This scale focuses on human functioning at the level of body, the whole person and the person within the social/environmental context. It classifies functioning of the affected body part, and the whole person in terms of impairment to bodily function and structure, limitation of activity and restriction to participation. It is designed to measure the effectiveness of an intervention using a patient-focused measure rather than the more traditional medical focus. For example, a patient with bronchiectasis who has had three admissions to hospital for chest infections over the last year is taught an airway clearance technique to assist sputum clearance. Over the next 12 months the outcome measure important to the patient is the ability to maintain a full-time job; while the outcome measure important to the Area Health Service is the cost saving achieved by a reduction in hospital admissions. Thus when selecting an outcome measure it is important to take into account for whom the data is needed.