Physical Examination in Respiratory System

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Physical Examination in Respiratory System
Zhao Li, M.D.
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Skeletal landmarks
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Anterior imaginary lines and landmarks
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Lateral imaginary lines
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Posterior imaginary lines and landmarks
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Anterior view of lobes
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Posterior view of lobes
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Right lateral view of lobes
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Left lateral view of lobes
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Thoracic deformity
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Inspection(1)

• Respiratory movement
• Abdominal breathing male adult and child
• Thoracic breathing female adult

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Inspection(2)

• Respiratory rate 16-18 f/min
• Tachypnea gt20 f/min
• Bradypnea lt12 f/min

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Inspection(2)

• Shallow and fast
• respiratory muscular paralysis, elevated
  intraabdominal pressure, pneumonia, pleurisy
• Deep and fast
• Agitation, intension
• Deep and slow
• Severe metabolic acidosis (Kussmauls breathing)

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Inspection (3)

• Respiratory rhythm
• Cheyne-Stokes breathing
• Biots breathing
• _____Decreased excitability of
  respiratory center
• Inhibited breathing
• Sudden cessation of breathing due to chest pain
• Pleurisy, thoracic trauma
• Sighing breathing
• Depression, intension

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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

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Percussion
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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

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2. Affected factors

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

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3. Classification

• Resonance
• Normal
• Hyperresonance
• Emphysema
• Tympany
• Cavity , pneumothorax
• Dullness
• Hydrothorax, atelectasis
• Flatness
• Massive Hydrothorax, massive atelectasis

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4. Normal sound

• Lungs sound in percussion
• Resonance
• Slight dullness in some areas (upper, right,
  back) due to thickness of muscles and skeletons

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4. Normal sound

• Border of lungs in percussion
• Apex of lungs
• Kronigs 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
• Downward emphysema
• Upward atelectasis, intraabdominal pressure
  increased

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4. Normal sound

• Shifting range of bottom of lung

• Decreased emphysema, atelactasis, fibrosis,
  pulmo. edema, pneumonia
• Detected impossibly pleura adhesion, massive
  hydrothorax, pneumothorax, diaphragmatic
  paralysis

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5. Abnormal sound

• Dullness, flatness, hyperresonance or tympany
  appear in the area of supposed resonance.
• Unchanged sound (resonance)
• The depth of the lesion gt 5 cm
• The diameter of the lesion ? 3 cm
• Mild hydrothorax

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5. Abnormal sound

• Dullness or flatness
• Decreased containing gases in alveoli
• Pneumonia
• Atelectasis?
• TB
• Pulmo. embolism
• Pulmo. edema
• Pulmo. fibrosis

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5. Abnormal sound

• Dullness or flatness
• No gases in alveoli
• Tumor
• Pulmo. Hydatid (???)
• Pneumocystis (???)
• Non-liquefied lung abscess
• Others
• Hydrothorax
• Pleural thickness

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5. Abnormal sound

• Hyperresonance
• Emphysema
• Tympany
• Pneumothorax
• Large cavity (TB, lung abscess, lung cyst)
• Amphorophony (???)
• Large and shallow cavity with smooth wall
• Tension pneumothorax

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5. Abnormal sound

• Tympanitic dullness (???)
• Decreased tension and gases in alveoli
• Atelectasis
• Congestive or resolution stage of pneumonia
• Pulmo. edema

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5. Abnormal sound

• Special areas on percussion in moderate
  hydrothorax

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Auscultation
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Order of auscultation
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Sound of auscultation

1. Normal breath sound
2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance (????)
5. Pleural friction rub

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1. Normal breath sound

• 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

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2. Abnormal breath sound

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

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Abnormal vesicular breath sound(1)

• Decreased or disappeared
• Limited movement of thoracic wall
• Respiratory muscle weakness
• Obstruction of airway
• Compressed atelectasis
• Hydrothorax or pneumothorax
• Abdominal diseases ascites, large tumor
• Increased
• Increased movement of respiration
• Exercise, fever, anemia, metabolic acidosis,
  compensation (single lung)

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Abnormal vesicular breath sound (2)

• Prolonged expiration
• ___ uncompleted obstruction and / or decreased
  alveolar elasticity
• Bronchitis
• Asthma
• emphysema

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Abnormal vesicular breath sound (3)

• Cogwheel breath sound
• TB
• Pneumonia
• Coarse breath sound
• ____ not smooth in airway due to swollen or
  exudation
• bronchitis
• Early stage of pneumonia

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Abnormal bronchial breath sound (tubular breath
sound)

• Bronchial breath sound appears in the area where
  vesicular breath sound is supposed to appear
  because of increased sound transmission or
  resonance.
• Consolidation lobar pneumonia (consolidation
  stage)
• Large cavity TB, lung abscess
• Compressed atelectasis hydrothorax, pneumothorax
  

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Abnormal bronchovesicular breath sound

• Bronchovesicular breath sound appears in the area
  where vesicular breath sound is supposed to
  appear.
• The lesion is relatively smaller, deeper or mixed
  with normal lung tissue.
• bronchopneumonia
• TB
• Early stage of lobar pneumonia
• Upper area of hydrothorax

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3. Adventitious sound

• moist Crackles
• Rhonchi (wheezes)

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Moist crackles

• 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.

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Characteristics of crackles

1. Adventitious sound
2. Intermittent
3. Appeared in phase of inspiration or early
   expiration
4. Constant in site
5. Unchanged in character
6. Medium and fine crackles exist meantime
7. Less or disappeared after cough sometimes

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Classification of moist crackles(1)

• According to intensity of the sound
• Loud moist crackles
• Slight moist crackles

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Classification of moist crackles(2)

• According to diameter of the airway crackles
  appeared
• Coarse trachea, main bronchi, or cavity
• Bronchiectasis, pulmo. edema, TB, lung abscess,
• coma (wheezy phlegm, ??)
• Medium bronchi
• bronchitis, bronchopneumonia

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Classification of moist crackles(3)

• Fine bronchioli
• Bronchiolitis, Pneumonia, pulmo. congestion,
• pulmo. embolism
• Velcro
• Interstitial lung disease
• Crepitus
• Bronchiolitis, alveolitis, early pneumonia
  (congestion),
• elder subject, pat. lying in bed for long
  time

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Site of crackles

• Local local lesion
• Pneumonia
• TB
• Bronchiectasis
• Both bases
• Pulmo. congestion
• Bronchopneumonia,
• Full fields
• Acute pulmo. Edema
• Severe bronchopneumonia

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Rhonchi (wheezes)

• 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 (lymph node, mediastinal tumor)

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Characteristics of rhonchi

• Adventitious sound
• High pitch
• Dominance in phase of expiration
• Variable intensity, character, site or spread
• Wheezing (appeared in main bronchi)

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Classification of rhonchi

• Sibilant (???,??)
• Bonchioli, smaller bronchi
• Sonorous (??,??)
• Trachea, main bronchi

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Site of rhonchi

• Both fields
• Asthma
• Chronic bronchitis
• Acute left heart failure (cardiac asthma)
• Local site
• Tumor
• Endobronchial TB

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Vocal resonance

• Increased sound transmission due to changed
  density of lung tissue
• Bronchophony (?????)
• Consolidation
• Pectoriloqny (???)
• Massive consolidation
• Egophony (???)
• Upper area of hydrothorax
• Whispered (???)
• Consolidation

Increased density of lung tissue Consolidation
vs Atelectasis
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Pleural friction rub

• Cellulose exudation in pleurisy (rough pleura)
• Area of auscultation
• inferolateral thoracic wall (maximal shifting
  area of lung)
• Friction rub disappeared if holding breath
• Friction rub appeared both breath and heart beat
  
• mediastinal pleurisy
• Causes
• Tuberculous pleurisy
• Pulmo. embolism
• Uremia
• Pleural mesothelioma

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Main symptoms and signs in common respiratory
diseases
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Labor pneumonia
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Symptoms

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

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Signs (1)

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

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Signs (2)

• Congestion stage
• Decreased movement of respiration in affected
  area
• Increased vocal fremitus
• Dullness
• Crepitus

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Signs (3)

• Consolidation stage
• Obviously increased vocal fremitus (resonance)
• Dullness or flatness
• Abnormal bronchial breath sound (tubular breath
  sound)
• Pleural friction rub
• Resolution
• Moist crackles

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Chronic bronchitis with emphysema
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Symptoms

• Chronic productive cough
• White mucous sputum or pus sputum (infection)
• Usually exacerbation in winter
• Morning cough
• To last more than 3 months
• Exertional dyspnea
• Breathlessness (dyspnea)
• Chest depress

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Signs

• Barrel chest
• Movement of respiration
• 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)

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Bronchial asthma
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Symptom

• Expiratory dyspnea with wheezing

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Signs

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

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Hydrothorax(pleural effusion)
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Symptoms
? 300ml no obvious symptoms gt500ml
breathlessness, chest depress

• Dry cough
• Chest pain
• Disappeared with growing of pleural effusion
• Reappeared with the fluid decreasing
• Affected side lying
• Dyspnea, orthopnea, palpitation
• The symptoms of underlying disease

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Signs (Moderate to massive effusion)

• 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
• Decreased or disappeared vocal resonance
• Pleural friction rub
• Abnormal bronchial breath sound in upper area of
  the fluid

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Pneumothorax
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Symptoms

• Sudden chest pain
• Dyspnea
• Forced sitting position
• Unaffected side lying
• Dry cough
• Tension pneumothorax
• Progressive dyspnea
• Severe sweat
• Tyckycardia
• Tension, agitated
• Cyanosis
• Respiratory failure

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Signs

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