Emphysema physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Chronic obstructive pulmonary disease can be diagnostically evaluated by physical examination through auscultation. Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases. Findings on general physical examination can be cyanosis, tachypnea, use of accessory respiratory muscles, paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign), elevated jugular venous pulse and peripheral edema. Pulmonary examination in can be barrel chest (emphysema), wheezing, hyperresonance, crackles and rhonchi. A physical examination may reveal signs of "pink puffers". Patients may lean forward with arms extended and/or resting on something to help them breathe ("orthopenic breathing"). When lung auscultation and chest percussion is performed a hyperresonant sound is heard. In later stages the patient may also exhibit symptoms of hypoxia-induced cyanosis, or the appearance of a blue-to-purplish discoloration of the skin, due to increased levels of deoxyhemoglobin in the blood.

Physical Examination

Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases.

Appearance of the Patient

  • General appearance:
    • Pursed lips, adopting a tripod position, using accessory muscles.
    • Thin patient with barrel chest
    • Barrel chest may cause distant heart sound
    • Pink puffers. This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why mild emphysema patients do not appear cyanotic as chronic bronchitis (another COPD disorder) sufferers often do; hence they are "pink puffers" (able to maintain almost normal blood gases through hyperventilation) and not "blue bloaters" (cyanosis; inadequate oxygen in the blood). However, any severely chronically obstructed (COPD) respiratory disease will result in hypoxia (decreased blood partial pressure of oxygen) and hypercapnia (increased blood partial pressure of Carbon Dioxide)
  • Signs of right heart failure
    • Elevated jugular venous pulse (JVP)
    • Peripheral edema can be observed.
  • Clinical signs on at the fingers include cigarette stains (although actually tar) and asterixis (metabolic flap) at the wrist if they are carbon dioxide retainers (NOTE: Finger clubbing is NOT a general feature of emphysema).
  • Cyanosis
  • Tachypnea

Lungs

Inspection

  • Hyperinflation (barrel chest)
  • Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)

Percussion

  • Hyperresonance

Auscultation

  • Prolonged expiration; wheezing
  • Diffusely decreased breath sound
  • Additional sounds - coarse crackles with inspiration
  • Examination of the chest reveals increased percussion notes (particularly over the liver) and a difficult to palpate apex beat (all due to hyperinflation), decreased breath sounds, audible expiratory wheeze. Classically,clinical examination of an emphysematic patient reveals no overt crackles, however, in some patients the fine opening of airway 'popping' (dissimilar to the fine crackles of pulmonary fibrosis or coarse crackles of mucinous or oedematous fluid) can be auscultated. This is known as "Barclay's sign".

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