Chronic obstructive pulmonary disease physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Philip Marcus, M.D., M.P.H. [2]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [3]

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

Physical Examination

Physical examinations 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

• Cyanosis
• Tachypnea
• 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)
• Elevated jugular venous pulse (JVP)
• Peripheral edema can be observed.

Lungs

Inspection

• Hyperinflation (barrel chest)

Percussion

• Hyperresonance

Auscultation

• Prolonged expiration; wheezing
• Diffusely decreased breath sound
• Additional sounds - coarse crackles with inspiration

	Specific Features of Emphysema	Specific Features of Chronic Bronchitis
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)	Blue bloaters they are so named as they have almost normal ventilatory drive (due to decreased sensitivity to carbon dioxide secondary to chronic hypercapnia), are plethoric (red face/cheeks due to a polycythemia secondary to chronic hypoxia) and cyanotic (due to decreased hemoglobin saturation). Signs of right heart failure or cor pulmonale such as edema and cyanosis can be seen.
Lungs	Inspection Hyperinflation (barrel chest) Tachypnea 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".	Inspection Respiratory distress indicated by use of accessory respiratory muscles Hoover's sign, presenting as paradoxical indrawing of lower intercostal spaces, is evident Auscultation Prolonged expiration; wheezing Diffusely decreased breath sound Coarse crackles with inspiration Coarse rhonchi
HEENT	Elevated jugular venous pulse (JVP)	Elevated jugular venous pulse (JVP)
Heart	Signs of right heart failure Muffled heart sounds Due to overdistention of lungs	Distant heart sounds, sometimes best heard in the epigastrium Muffled heart sounds Due to overdistention of lungs
Extremity	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	Peripheral edema