Download respiratiory eximination

EXAMINATION OF RESPIRATORY SYSTEM
Examination of the respiratory system is carried out with a simultaneous general
assessment. For the examination the patient should be resting comfortably on a bed or
couch, supported by pillows so that they can lean back comfortably at an angle of 45 °.
OBSERVATI
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ON
INSPECTI
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PALPATI
ON
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PERCUSSI
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AUSCULTATI
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OBSERVATION:
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The hands should be inspected for clubbing, pallor or cyanosis. The lips and tongue should
be inspected for central cyanosis. A breathless patient may be using the accessory muscles of
respiration. Breathing out through pursed lips is observed in patients suffering from severe
COPD.
INSPECTION:
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A careful inspection must be done to look out for any visible scars as a result of previous
injury or previous surgery, lumps under the skin or any lesions on the skin. Chest should be
inspected for it shape and its movement.
SHAPE OF THE CHEST:
The normal chest is bilaterally symmetrical, with smooth contours and elliptical in crosssection with a slight recession below the clavicle. Its transverse diameter is greater than the
anterior posterior diameter with the ratio being 7:5. The chest may be distorted by disease of
the ribs or spinal vertebrae, or by underlying lung disease.
Barrel Chest:
It is most easily appreciated as increased anteroposterior diameter. The sub-costal angle is
wide, angle of Louis unduly prominent, sternum is more arched, ribs show less obliquity and
spine is concave forward. It occurs as a result of over-inflated lungs seen in case of COPD,
usually emphysema, but may be seen normally during infancy and accompanying normal
aging.
Funnel Chest (Pectus Excavatum or Cobbler’s chest):
It is characterized by a depression in the lower portion of the sternum. It may be congenital
as a consequence of Rickets in childhood or may be occurring as an occupational deformity
in cobblers. Due to the sternal depression, the normal cardiac shadow may appear enlarged
on X-ray chest (Known as Pomfret’s heart.)
Pigeon Chest (Keeled chest or Pectus Carinatum):
Sternum is displaced anteriorly, increasing the anteroposterior diameter and the costal
cartilages adjacent to the protruding sternum are depressed. It is often associated with bead
like enlargement at the costochondral junction, known as Rickety Rosary and a transverse
groove seen passing outwards from the xiphisternal junction to the mid-axillary line, known
as Harrison’s Sulcus.
Traumatic Flail Chest:
In case of multiple ribs fracture, paradoxical movements of the thorax may be seen. As
downward movement of the diaphragm during respiration decreases the intrathoracic
pressure on inspiration, the injured area arches inward and on expiration, it arches outward.
Flat Chest (Phthinoid chest):
In chronic nasal obstructive diseases like adenoid lymphoid hypertrophy or bilateral
Pulmonary Koch’s or childhood rickets, due to obstruction to the airway, the anteroposterior
diameter is reduced.
Thoracic Kyphoscoliosis:
Kyphosis (forward bending of spine) or scoliosis (lateral bending of spine) can lead to
asymmetry of the chest, and if severe may significantly restrict lung movement.
Bulging, Depression or Flattening:
It may be observed that one side of the chest may bulge outwards. This is usually observed in
pleural effusion, pneumothorax, tumors, aneurysms, cardiomegaly, etc. Specific localized
bulging is seen in aortic aneurysm, pericardial effusion, liver abscess, chest wall tumors, etc.
Similarly, one side of the chest may be flattened or depressed. It is usually seen associated
with fibrosed or collapsed lungs, pleural adhesions or one sided muscle wasting as seen in
poliomyelitis.
MOVEMENT OF THE CHEST:
Movements of the chest should be well observed for their symmetry, rate, rhythm and type of
respiration. Normally both the sides of the chest wall move uniformly without bulging or indrawing of the interspaces. Intercostal recession, a drawing-in of the intercostal spaces with
inspiration may indicate severe upper airways obstruction, or tumours of the trachea. In
COPD the lower ribs usually move inwards on inspiration instead of the normal outwards
movement.
DIMINISHED MOVEMENTS:
Unilaterally diminished movements are seen in conditions such as obstruction to the main
bronchus, fibrosis of lungs, pleural adhesions, severe lung collapse, consolidations, pleural
effusion, hydropneumothorax, etc.
Bilaterally diminished movements are seen in cases of emphysema, bilateral fibrosis,
bilateral collapse, bilateral consolidation, hydropneumothorax, bronchial asthma, etc.
RESPIRATORY RATE:
To view details about respiratory rate kindly refer to the General Examination Section.
DYSPNOEA:
Dyspnoea is defined as difficult or labored breathing. It is a normal symptom of heavy
exertion but becomes pathological if it occurs in unexpected situations.
Dyspnoea can be graded as follows:
GRADE DEGREE
DESCRIPTION
0
None
No shortness of breath on leveled road or uphill.
1
Mild
Trouble of shortness of breath on leveled road or walking uphill.
2
Moderate
Walking pace slower than the person of his same age.
3
Severe
Has to stop after walking a distance of about 100 yards.
4
Very severe Shortness of breath even on rest.
RESPIRATORY RHYTHM:
Normal process of respiration involves a regular rhythm of inspiration and expiration with
inspiration being longer than expiration.
Irregularities in Respiratory Rhythm can be of following types:
TYPE
DESCRIPTION
SEEN IN
Kussmaul’s
respiration
(Air hunger)
Characterized by deep and
rapid respiration
Diabetic ketoacidosis, alcoholics, uremia
and starvation ketoacidosis
CheyneStokes
respiration
Cyclical deepening and
quickening of respiration
(hyperapnoea), followed by
diminishing respiratory effort
and rate, sometimes with a
short period of complete
apnoea.
Severely ill patients, left ventricular
failure, narcotic drug poisoning especially
by opium or barbiturates, conditions of
increased intra-cranial pressure, damage
to cerebrum or diencephalon and
neurological disorders; occasionally seen
in elderly patients during sleep, without
any obvious serious disease
Biot’s
respiration
Irregularly regular respiration
Meningitis and raised intra-cranial
pressure
Stridor
Prolonged, high pitched,
inspiratory sound through the
obstructed upper airway
Laryngeal or tracheal obstruction,
laryngeal diphtheria, mediastinal growths
or tumors
Wheezing
Prolonged expiration through
Bronchial asthma, cardiac asthma, renal
an obstructed lower airway,
asthma
bronchi or bronchioles,
reflecting narrowing of smaller
airways
Stertor
Death Rattle; commonly
occurring in a dying person
Coma or deep sleep
TYPE OF BREATHING:
In males and some females breathing normally is abdominothoracic. In case of
thoracoabdominal breathing, thoracic movements are more prominent as compared to
abdominal movements.
TYPE OF
BREATHING
DESCRIPTION
SEEN IN
ABDOMINAL
Abdominal movements are predominant
and thoracic movements are diminished
Pleurisy, Lung collapse
THORACIC
Thoracic movements are predominant
and abdominal movements are
diminished
Diaphragmatic paralysis,
peritonitis, severe ascites
INSPECTION OF MEDIASTINUM
A normal mediastinum is central. The shift of mediastinum can be detected by noting the
respective position of trachea and apex beat. In case of shift in mediastinum, the
sternocleidomastoid becomes more prominent on the side to which trachea is shifted. This
phenomenon is known as Trail Sign.
The position of mediastinum in various respiratory diseases is given as follows:
MEDIASTINUM CENTRAL
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MEDIASTINUM SHIFTED TO THE
SAME SIDE
Emphysema
Pneumonia
Interstitial fibrosis
Lung abscess
Bronchial asthma
Bronchitis
Bronchiectasis
PALPATION:
IDENTIFY TENDER AREAS:

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
Collapse
Pleural
thickening
Fibrosis
MEDIASTINUM - SHIFTED TO
THE OPPOSITE SIDE

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
Pneumothorax
Pleural effusion
Hydropneumothorax
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Carefully palpate any area where pain has been reported or where lesions or bruises are
evident. Assess any observed abnormalities such as masses or sinus tracts (blind,
inflammatory, tube-like outlets opening onto the skin)
TEST CHEST EXPANSION:
Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and
parallel to the lateral rib cage and slide them medially just enough to raise a loose fold of skin
on either side between your thumb and the spine. Ask the patient to inhale deeply. Observe
the distance between your thumbs as they move apart during inspiration and feel for the range
and symmetry of the rib cage as it expands and contracts.
LYMPH NODES PALPATION:
The lymph nodes in the supraclavicular fossae, cervical regions and axillary regions should
be palpated. If they are enlarged this may be as a result of secondary spread of malignancy
from the chest.
TRACHEA AND HEART PALPATION:
The positions of the cardiac impulse and trachea should be determined. Putting the second
and fourth fingers of the examining hand on each edge of the sternal notch, use the third
finger to assess whether the trachea is central or deviated to any side. Displacement of the
cardiac impulse without displacement of the trachea may be due to scoliosis, congenital
funnel depression of the sternum or enlargement of the left ventricle. In the absence of these
conditions a significant displacement of the cardiac impulse or trachea, or of both together,
suggests that the position of the mediastinum has been altered by disease of the lungs or
pleura.
TACTILE VOCAL FREMITUS:
It is defined as tactile perception of vibrations communicated to the chest wall from the
bronchopulmonary tree during the act of phonation.
To detect fremitus, use either the ball of the palm, base of the fingers or the ulnar surface of
your hand to optimize the vibratory sensitivity of your hand. Ask the patient to repeat the
words like “ninety-nine” or “one-one-one.” Palpate and compare bilaterally symmetric areas
of the lungs for its fremitus. Identify and locate any areas of increased, decreased, or absent
fremitus.
TACTILE VOCAL FREMITUS
SEEN IN
INCREASED
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Pyogenic consolidation
Tuberculous consolidation
Pulmonary infarction
Surrounding a malignant lesion
DECREASED
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Emphysema
Pulmonary fibrosis
Lung collapse
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Bronchial asthma
Bronchial obstruction
Pleural effusion
Pneumothorax
Hydropneumothorax
ABNORMAL VIBRATIONS:
PLEURAL FRICTION RUB – It is a vibration felt as a rub usually during the peak of
inspiration or early expiration, commonly seen in case of pleurisy.
BRONCHIAL FREMITUS – It is a vibration that can be palpated on the chest wall over a
bronchus. It is often felt in diseases like bronchitis, bronchial asthma and COPD.
PALPABLE RALES – They are felt in conditions like bronchiectasis, pulmonary fibrosis and
pulmonary congestion.
PERCUSSION:
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Percussion helps you to access whether the underlying tissues are air-filled, fluid-filled, or
solid.
ABNORMAL NOTES:
In conditions when the amount of air in the alveoli decreases, the lungs fail to vibrate
sufficiently to the percussion stroke. This occurs in conditions such as –
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Consolidations
Infiltrations
Fibrosis
Lung Collapse
DULL NOTES:
An impaired note of a higher degree is called a dull note. It is felt in conditions like –
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Consolidations
Infiltrations
Fibrosis
Lung Collapse
Pleural Thickening
STONY DULL NOTES:
It is a type of percussion note which is completely devoid of resonance or it may express
extreme level of dullness. It is mainly due to underlying fluid, as fluid dampens the vibrations
or due to underlying fibrosis, mass or thickening. It is a common associate in conditions like
–

Pleural Effusion

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Lung Fibrosis
Pleural Thickening
Solid Intrathoracic tumor
TYMPANY:
Tympany is a hollow drum-like resonant sound produced when a gas-containing cavity is
tapped sharply. It may be felt over the chest wall in following conditions –

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
Emphysema
Pneumothorax
Superficial empty cavities
SUB TYMPANY:
It is also known as Skodaic resonance. It is a hyperresonant note of a boxy quality occurring
due to relaxed lungs, felt just above the levels of pleural effusion.
HYPER-RESONANCE:
It is a note of a loud intensity, low pitch and lasts for a longer time, ranging between normal
resonance and tympany and may be well elicited with the chest in full inspiration while
percussing. It occurs in conditions like –
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Pneumothorax
Emphysema
Large Cavities
Congenital Lung Cyst
Emphysematous Bullae
Eventration of diaphragm
BELL TYMPANY:
This is a high pitched tympanic sound heard over the chest wall in cases of massive
pneumothorax. This sound is heard by placing a silver coin on the affected side and
percussion carried out with a second coin. The ear or stethoscope may be held over the
opposite side of the chest to hear the emitted sound. A clear bell-like sound resembling the
sound of a ‘Hammer stroked on an anvil’ is heard.
KRONIG’S ISTHMUS:
Kronig’s Isthmus is a band of resonance approximating to about 5-7 cm. in width, which
connects lung resonance of the anterior and posterior aspects of each side of the chest. It is
bounded medially by dullness of the neck muscles and laterally by the dullness of pectoral
muscles. Absence of this sound on either side suggests pulmonary fibrosis as a consequence
of TB. Increased width of resonance is suggestive of emphysema.
LIVER AND CARDIAC DULLNESS:
Normal liver dullness is present in the right 5th intercostal space in the mid-clavicular line,
7th space in the anterior axillary line and 9th space in scapular line.
CHARACTER OF LIVER DULLNESS
SEEN IN
RAISED
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
Amoebic Liver Abscess
Pyogenic Liver Abscess
Diaphragmatic Paralysis
Lower Lobe Collapse of lungs
LOWERED




Emphysema
Right-sided Pneumothorax
Terminal Cirrhosis
Air in the Peritoneal Cavity
Cardiac dullness is felt on the left side of the lung field due to the presence of the heart. It is
felt normally in the 3rd and 4th parasternal line and 5th left mid-clavicular line.
CHARACTER OF CARDIAC DULLNESS
SEEN IN
INCREASED


Cardiomegaly
Shift of heart to the left
DECREASED


Emphysema
Left-sided Pneumothorax
TIDAL PERCUSSION:
Percussion done of the upper border of the liver with dullness on the right side anteriorly on
inspiration and expiration helps to determine the range of lung expansion.
It is restricted in conditions like –
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

Pulmonary disease at the base of the lung
Pulmonary Fibrosis
Empyema
Hepatic Amoebiasis
Sub-diaphragmatic abscess
TRAUBE’S AREA:
This area is bound above by lung resonance, below by costal margins, on the right by the left
border of liver and on the left by spleen. It is normally occupied by stomach and the note
developed is tympanic. Dull note in Traube’s area suggests pleural effusion on the left side.
SHIFTING DULLNESS:
In patients with hydropneumothorax in sitting position, there is a hyperresonant note felt
above followed by a note of dullness felt below. On changing the patient’s posture to supine,
this area of dullness of the fluid changes as air and fluid levels shift.
AUSCULTATION:
BREATH SOUNDS:
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Normal breath sounds are vesicular, bronchial and broncho-vesicular.
VESICULAR:
These sounds are soft and low pitched, heard through inspiration, continue without pause
through expiration, fading about one third of the way through expiration. It is typically
rustling due to the passage through alveoli which selectively transmit sounds of lower
frequency and dampen the higher frequency sounds. It is normally heard over the chest.
BRONCHIAL:
These sounds are louder and higher in pitch, with a short silence between inspiratory and
expiratory sounds. Expiratory sounds last longer than inspiratory sounds. In this type, both
higher and lower frequency sounds are conducted as alveolar phase is absent. They may be
normally heard over the manubrium if at all heard.
There are 3 types of bronchial breath sounds –
TYPE
CHARACTER
SEEN IN
TUBULAR
High pitched bronchial sound
Consolidations, above the level of
pleura and above the cavities
CAVERNOUS Low pitched bronchial sound
Irregular cavity
AMPHORIC
Smooth walled cavity, open
pneumothorax
Low pitched bronchial sound with
high pitched over tones
BRONCHO-VESCICULAR:
These sounds are with inspiratory and expiratory sounds about equal in length, at times
separated by a silent interval. It is normally heard over the 1st and 2nd interspaces anteriorly
and between the scapulae. It may be heard as an abnormal component in cases of –



Asthma
Chronic Bronchitis
Emphysema
ABNORMAL/ FOREIGN SOUNDS:
RALES (CRACKLES):
They are crackling sounds originating in the smaller airways and alveoli as a result of an
explosive opening of the airways (during inspiration) in that particular part of the lung that is
deflated (during expiration). Crackles result from air bubbles flowing through secretions or
lightly closed airways during respiration.
Types of Rales:
TYPE OF RALE
DESCRIPTION
SEEN IN
EARLY
INSPIRATORY
Result from openings of large airways being
closed by air-trapping mechanism during the
previous expiration, appear soon after
inspiration, and are often coarse and few in
number.
Chronic bronchitis
MIDINSPIRATORY
--
Bronchiectasis
LATE
INSPIRATORY
May begin in the first half of inspiration but
must continue into late inspiration. They are
usually fine and fairly profuse.
Interstitial lung disease
(fibrosis), early
congestive heart failure
EXPIRATORY
Associated with severe airway obstruction.
Chronic bronchitis and
Asthma
RHONCHI (WHEEZE):
They occur when air flows rapidly through bronchi that are narrowed to an extent of closure.
Causes of wheezes that are generalized throughout the chest include 




Bronchial Asthma
Chronic Bronchitis
COPD
Congestive heart failure (Cardiac Asthma)
Malignancy
In asthma, wheezes may be heard only in expiration or in both phases of the respiratory cycle.
In severe COPD, the patient is no longer able to force enough air through the narrowed
bronchi to produce wheezing. A persistent localized wheeze suggests a partial obstruction of
a bronchus, as by a tumor or foreign body. It may be inspiratory, expiratory, or both.
Types of Rhonchi:


Polyphonic – This type of rhonchi consists of expiratory sound containing several
notes of different pitch. It results from simultaneous oscillatory movement of several
large bronchi.
Monophonic – It is a sound emitted from a single airway which is constricted. It is
seen in conditions like chronic bronchitis and emphysema.
STRIDOR:
Stridor is a loud inspiratory sound heard over the airways due to obstruction of the respiratory
tract.


Laryngeal Stridor – It is a high pitched sound audible over the larynx due to the
obstruction of larynx by a foreign body or diphtheria. It is regarded as a medical
emergency.
Tracheal Stridor – It is a low pitched sound heard over the trachea due to tracheal
obstruction.
VOCAL RESONANCE:
Vocal resonance is the resonance in the chest occurring due to the sounds made by the voice
as a result of laryngeal vibrations. While testing vocal resonance, you are detecting vibrations
transmitted to the chest from the vocal cords as the patient repeats a phrase, usually the words
'ninety-nine'.
Vocal Resonance may be increased or altered as follows:
TYPE OF
RESONANCE
CHARACTER
SEEN IN
WHISPERING
PECTORILOQUY
Resonance is increased and the
Lung Consolidation
sounds heard are louder and clearer in
a consolidated lung more than an airfilled lung. Thus, even when the
patient whispers a phrase the sounds
may be heard clearly.
AEGOPHONY
Nasal or bleating character of voice
when auscultated.
Pleural effusion (above its
level), Lung consolidation
BRONCHOPHONY
Increased vocal resonance wherein
the sounds heard are loud and clear
but the words spoken are
indistinguishable.
Lung consolidation
SUCCUSSION
SPLASH
Splashing sound audible over the
chest wall by a stethoscope or an
unaided ear, when the patient is
shaken suddenly by the examiner.
Hydropneumothorax, large
cavity containing fluid and
air or herniation of stomach
or colon into the thorax
POST-TUSSIVE
SUCTION
Suction sound heard over the chest
wall during the long inspiratory spell
that follows a bout of cough.
Thin walled compressible
lung cavity communicating
with the bronchus
POST-TUSSIVE
RALES
Rales are not audible during normal
respiration but are audible after
making the patient cough. They
suggest cavity filled with thick
material which got dislodged during
Lung cavity filled with fluid
(most commonly lung
abscess)
coughing allowing the air to bubble
out through the remaining fluid, thus
producing the rales
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