physical examination in RESPIRATORY SYSTEM

Wednesday, May 3, 2023Respiratory System.

Physical Examination in Respiratory System

D.RT.VENKATES

AN C.R.R.I

GYNMC.


Anterior imaginary lines and landmarks

epigastric angle

Infraclavicular fossa

Anterior midline

Suprasternal fossa Supraclavicular fossa

Sternal line

Parasternal line

Midclavicular line


Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line


Posterior imaginary lines and landmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region


Anterior view of lobes


Posterior view of lobes


Right lateral view of lobes


Left lateral view of lobes


Thoracic deformity

Pectus excavatumBarrel chest

Kyphosis

1. Respiratory movement◦ Abdominal breathing: male adult and child ◦ Thoracic breathing: female adult

2. Respiratory rate: 16-18 f/min◦ Tachypnea: >20 f/min◦ Bradypnea: <12 f/min◦ Shallow and fast

respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy

◦ Deep and fast Agitation, intension

◦ Deep and slow Severe metabolic acidosis (Kussmaul’s breathing)


Inspection

3. Respiratory rhythm Cheyne-Stokes’ breathing Biot’s breathing _____Decreased excitability of respiratory

center Inhibited breathing

◦ Sudden cessation of breathing due to chest pain Pleurisy, thoracic trauma

Sighing breathing ◦ Depression, intension


Inspection

Palpation Thoracic expansion

◦ Massive hydrothorax, pneumonia, pleural thickening, atelectasis

Vocal fremitus (tactil fremitus) Pleural friction fremitus

◦ Cellulose exudation in pleura due to pleurisy

◦ Holding breathing disappeared

◦ Tuberculous pleurisy, uremia, pulmo embolism

Respiratory System.Wednesday, May 3, 2023

Percussion


1. Method

◦ Mediate Pleximeter: distal inter-phalangeal joint of left

middle finger Plexor: right middle finger tip

◦ Immediate◦ Order

Up to down, anterior to posterior


◦ Thickness of thoracic wall◦ Calcification of costal cartilage ◦ Hydrothorax◦ Containing gas in alveoli ◦ Alveolar tension◦ Alveolar elasticity


2. Affected factors

Resonance Normal

Hyperresonance Emphysema

Tympany Cavity or pneumothorax

Dullness Hydrothorax, atelectasis

Flatness Massive Hydrothorax


3. Classification

Lung’s sound in percussion Resonance Slight dullness in some areas (upper, right,

back) due to thickness of muscles and skeletons


4. Normal sound

Border of lungs in percussion Apex of lungs

Kronig’s isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema

Anterior border absolute cardiac dullness area

Lower border 6th, 8th, 10th intercostal space in midclavicular line,

midaxillary line, scapular line, respectively Down: emphysema Up: atelectasis, intraabdominal pressure goes up


4. Normal sound

4. Normal sound


sShifting range of bottom of lung

6-8 cm

Shifting range of bottom of lung

Along the scapular line

Percussing bottom of lung, marking

Asking the pat. to inspire deeply and hold


Asking the pat. to expire deeply and hold


Measuring the dist. between upper and lower lines

Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia

Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax,

diaphragmatic paralysis

Dullness, flatness, hyperresonance or tympany appear in the area of supposed resonance.

Unchanged sound (resonance)◦ The depth of the lesion > 5 cm◦ The diameter of the lesion 3 cm◦ Mild hydrothorax


5. Abnormal sound

Dullness or flatness Decreased containing gas in alveoli

◦ Pneumonia◦ Atelectasis?◦ TB◦ Pulmo. embolism◦ Pulmo. edema◦ Pulmo. fibrosis

No gas in alveoli◦ Tumor◦ Pulmo. Hydatid ◦ Pneumocystis ◦ Non-liquefied lung abscess

Others◦ Hydrothorax ◦ Pleural thickness


5. Abnormal sound

Hyperresonance Emphysema

Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)

Amphorophony Large and shallow cavity with smooth wall Tension pneumothorax

Tympanitic dullness Decreased tension and gas in alveoli

Atelectasis Congestive or resolution stage of pneumonia Pulmo. edema


5. Abnormal sound

5. Abnormal sound

Special areas on percussion in moderate hydrothorax


Damoiseau’s curve

Garland’s triangle area(tympanitic dullness)

Grocco’s triangle area(dullness)

Auscultation



Order of auscultation

1. Normal breath sound2. Abnormal breath sound3. Adventitious sound4. Vocal resonance


Sound of auscultation

Tracheal breath sound Bronchial breath sound

◦ Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra

Bronchovesicular breath sound◦ 1st, 2nd intercostal space

beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung

Vesicular breath sound◦ Most area of lungs


1. Normal breath sound

Bronchovesicular

Bronchial

Bronchial

Bronchovesicular

Abnormal vesicular breath sound Abnormal bronchial breath sound Abnormal bronchovesicular breath sound


2. Abnormal breath sound

1) Decreased or disappeared Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor

2) Increased Movement of respiration


Abnormal vesicular breath sound(1)

3) Prolonged expiration Bronchitis Asthma emphysema

4) Cogwheel breath sound TB Pneumonbreath soundia

5) Coarse Early stage of bronchitis or pneumonia


Abnormal vesicular breath sound (2)

Bronchial breath sound appears in supposed vesicular breath sound area

Consolidation: lobar pneumonia (consolidation stage) Large cavity: TB, lung abscess Compressed atelectasis: hydrothorax, pneumothorax


Abnormal bronchial breath sound (tubular breath sound)

Bronchovesicular breath sound appears in supposed vesicular breath sound area

◦ The lesion is relatively smaller or mixed with normal lung tissue


Abnormal bronchovesicular breath sound

(moist) Crackles Rhonchi (wheezes) Pleural friction rub


3. Adventitious sound

Mechanism During inspiration, air flow passes thin

secretion in the airway to rupture the bubbles, or to open the collapse of bronchioli due to adhesion by secretion.


Moist crackles

1. Adventitious sound2. Intermittent 3. Appeared in phase of inspiration or early

expiration4. Constant in site5. Unchanged in character6. Medium and fine crackles exist meantime7. Less or disappeared after cough


Characteristics of crackles

According to intensity of the sound1. Loud moist crackles2. Slight moist crackles

According to diameter of the airway crackles appeared1. Coarse: trachea, main bronchi, or cavity

Bronchiectasis, pulmo. edema, TB, lung abscess, coma2. Medium: bronchi

bronchitis, pneumonia3. Fine: bronchioli

pneumonia4. Crepitus:

Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time


Classification of crackles

1. Local: local lesion◦ Pneumonia, TB, bronchiectasis

2. Both bases◦ Pulmo. edema, bronchopneumonia, chronic bronchitis

3. Full fields ◦ Acute pulmo. edema, severe

bronchopneumonia, chronic bronchitis with severe infection


Site of crackles

Mechanism The turbulent flow is formed in trachea,

bronchi or bronchioli due to airway narrow or incomplete obstruction.

Causes ◦ Congestion◦ Secretion◦ Spasma◦ Tumor◦ Foreign subject◦ Compression


Rhonchi (wheezes)

1. Adventitious sound2. High pitch3. Dominance in phase of expiration4. Variable intensity of character or site 5. Wheezing


Characteristics of rhonchi

1. Sibilant ◦ Bonchioli, bronchi

2. Sonorous ◦ Trachea, main bronchi


Classification of rhonchi

1. Both fields◦ Asthma◦ Chronic bronchitis◦ Acute left heart failure

2. Local site◦ Tumor◦ Endobronchial TB


Site of rhonchi

1. Cellulose exudation in pleurisy (rough pleura)2. Area of auscultation

Anterolateral thoracic wall (maximal shifting area of lung)

3. Friction rub disappeared if holding breath4. Friction rub appeared both breath and heart beat: mediastinal pleurisy5. Causes

Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma


Pleural friction rub

Bronchophony ◦ Consolidation

Pectoriloqny ◦ Massive consolidation

Egophony ◦ Upper area of hydrothorax

Whispered ◦ Consolidation


Vocal resonance

Main symptoms and signs in common

respiratory diseases


Labor pneumonia


Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum


Symptoms

General signs◦ Acute facial features, blushing ◦ Nares flaring (dyspnea)◦ Cyanosis◦ Tachycardia◦ Simple herpes around lips


Signs (1)

Congestion Inspection Decreased respiratory movement Palpation Increased vocal r


Signs (2)

Chronic bronchitis with emphysema


Chronic productive cough White mucous sputum or pus sputum

(infection) Exertional dyspnea Breathlessness (dyspnea) Chest depression


Symptoms


Signs Barrel chest Movement of respiratory Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)

Bronchial asthma


Expiratory dyspnea with wheezing


Symptom

Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs


Signs

Hydrothorax(pleural effusion)


Dry cough Chest pain

◦ Disappeared with growing of pleural effusion ◦ Reappeared with the fluid decreasing

Affected side lying Dyspnea, orthopnea The symptoms of underlying disease


Symptoms

Tachypnea Limited movement of affected side Costal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Pleural friction rub Abnormal bronchial breath sound in upper area

of the fluid


Signs (Moderate to massive effusion)

Pneumothorax


Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough

Tension pneumonia◦ Progressive dyspnea◦ Tyckycardia◦ Cyanosis◦ Respiratory failure


Symptoms

Costal interspaces in affected side are wider Limited movement of affected side Decreased vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or

disappeared


Signs


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physical examination in RESPIRATORY SYSTEM

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