Asthma physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

The characteristic physical signs of asthma include: loud prolonged polyphonic expiratory wheeze and adventitious sounds such as rhonchi. Presence of wheeze is indicative of airway narrowing; however, the absence of wheeze indicates a silent lung characteristic of status asthmaticus delineated by widespread obstruction that results in significant airflow reduction and insufficient enough to produce a wheeze.

Physical Examination

Physical examination may be normal or can be characteristically present with a loud polyphonic expiratory wheeze. Nasal examination is mandatory to rule out associated conditions such as, aspirin sensitivity or allergic rhinitis.

Mild Episode

• Prolong end-expiratory wheeze
• In between attacks, chest is clear and no abnormal physical signs may be detectable.

Moderately Severe Episode

• Use of accessory muscles of respiration such as sternocleidomastoid and scalene muscles
• Increased respiratory rate
• Pulsus paradoxus (a fall of SBP between 10-20mmHg during inspiration)
• Hyper-resonant lungs
• Loud prolonged expiratory wheeze with a reduced inspiration to expiration ratio
• Vesicular breath sounds with prolonged respiration

Acute Severe Episode

• Patient has to sit upright with arms extended to support the upper chest (tripod position) that assist the use of accessory muscles of respiration
• Use of accessory muscles of respiration
• Increased respiratory rate greater than 30 cycles per minute
• Increased heart rate
• Pulsus paradoxus (a fall of SBP greater than 20-40 mmHg during inspiration)

Imminent Respiratory Failure

• Profuse sweating
• Severe hypoxia resulting in central cyanosis and hypoventilation
• Paradoxical thoraco-abdominal breathing
• Pulsus paradoxus , wheeze and breath sounds are typically absent secondary to severe airway obstruction, representing a silent chest which is an ominous sign.

Chronic Asthma

• Persistent scattered rhonchi

Associated Conditions

• Conjunctival congestion, transverse crease on nose as a consequence of constant rubbing and pale swollen nasal mucosa are suggestive of associated allergic rhinitis.
• Triad of asthma, nasal polyps and rash is indicative of aspirin sensitivity.
• Presence of clubbing in asthma may be secondary to interstitial lung disease.