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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 | ON INSPECTI ON | PALPATI ON | PERCUSSI ON | AUSCULTATI ON OBSERVATION: Top 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: Top 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 MEDIASTINUM SHIFTED TO THE SAME SIDE Emphysema Pneumonia Interstitial fibrosis Lung abscess Bronchial asthma Bronchitis Bronchiectasis PALPATION: IDENTIFY TENDER AREAS: Collapse Pleural thickening Fibrosis MEDIASTINUM - SHIFTED TO THE OPPOSITE SIDE Pneumothorax Pleural effusion Hydropneumothorax Top 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 Pyogenic consolidation Tuberculous consolidation Pulmonary infarction Surrounding a malignant lesion DECREASED Emphysema Pulmonary fibrosis Lung collapse 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: Top 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 – 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 – 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 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 – 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 – 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 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 – 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: Top 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 Top