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50 JULY 2016 | EMSWORLD.com last up to 30 seconds. Cycles can last up to 2 minutes. Common causes include head trauma, stroke, hypoxia and brain tumors. Neck exam—Observe for JVD and hepatojugular reflux (HJR). With the examiner on the right side of the patient, place the patient supine with the head up at about 30 degrees and turned away from the examiner. Then observe the exposed neck for JVD. With the patient in the same position, press down on the right upper quad- rant of the abdomen over the liver. If the liver is engorged with blood due to right-sided CHF, the jugular vein will become more distended, making JVD more pronounced and obvious. These are both common signs of CHF. In addition, JVD may be present with tension pneumothorax. Chest » Inspection: Inspecting the chest is often neglected in the pre- hospital setting, but valuable information regarding the level of respiratory distress and the rate and quality of breathing can be determined this way. As you visualize the chest, look for intercostal muscle retractions, rate and depth of breathing, and equal expan- sion of the chest wall. Note whether the patient has a barrel chest (indicative of COPD). » Palpation: Respiratory emergencies with associated chest pain should prompt palpation of the chest wall. Palpate over the affected area and note whether the pain can be reproduced. Chest pain asso - ciated with respirations or coughing is defined as pleuritic chest pain and associated with pleurisy, costochondritis, pulmonary embolus, pneumothorax, pneumonia and pericarditis. Pneumothorax com- monly produces subcutaneous air that can be felt as a crackling sensation while palpating over the affected area of the chest wall. » Auscultation: The ability to distinguish adventitious lung sounds is a necessary skill to diagnose respiratory emergencies. Too often lung sounds are omitted as part of the physical exam unless the chief complaint is respiratory in nature. As mentioned in earlier articles, lung sounds should be assessed on all patients as part of a limited prehospital physical exam. Lungs sounds can be difficult to assess in the field. To improve auscultation, eliminate background noises whenever possible. Posi- tion the patient seated if they're able. Ask patients not to speak during auscultation and to take slow, deep breaths with their mouth open. Place the stethoscope on the patient's bare skin. Begin aus- cultation on the posterior thorax at the apex. Move from one side to the other, comparing lung sounds. Listen for a full respiratory cycle (one inhalation, one exhalation), continue moving inferiorly to the bases. Repeat on the anterior chest. Abnormal lung sounds can be decreased or absent or adven- titious (e.g., crackles, rhonchi, wheezing, stridor or pleural rub). These sounds can be heard by themselves but often are heard in combination. » Normal lung sounds: There are essentially two types of nor- mal lung sounds, vesicular and bronchovesicular. Vesicular lung sounds are soft and low-pitched and are auscultated over most of the peripheral lung tissue. Bronchovesicular lung sounds are heard anteriorly over at the sternal borders at the first and second inter- costal spaces and posteriorly between the scapulae. They have a medium pitch since they are auscultated over main-stem bronchi. It is important for the paramedic to listen to many normal patients in order to train the hearing skills to identify abnormal breath sounds. » Decreased breath sounds: Decreased breath sounds may be caused by chronic conditions such as COPD (emphysema and chron- ic bronchitis) and asthma, or acute conditions (e.g., spontaneous pneumothorax). Other causes include hypoventilation or obesity. » Crackles: Crackles can be described as fine or coarse. Crackles are associated with pulmonary edema secondary to left ventricular failure, COPD, pneumonia, bronchitis and asthma. Fine crackles have a sound similar to rubbing your hair between your index finger and thumb. There are subtle differences in the quality of the crackles depending upon the underlying etiology. It takes time and experience to learn to decipher those differences. » Rhonchi: Rhonchi are gurgling, rattling type sounds and are indicative of secretions in the larger airways. Rhonchi can be gen- eralized as in bronchitis or localized as with pneumonia. » Wheezing: Wheezing is a high-pitched whistling sound and occurs in response to bronchospasm. Asthma, COPD, bronchitis, pneumonia, CHF, pulmonary embolism and allergic reactions can all produce wheezing. Early wheezing is first heard on exhalation. As bronchospasm progresses, it can be heard on the inhalation phase as well. As it progresses even further, breath sounds may become significantly decreased or even absent. This is an ominous sign that the patient is not able to move air sufficiently to produce wheezing. This means respiratory failure is imminent. A common CHF finding is pitting edema in the lower extremities.