Physical Examination in Respiratory System

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Physical Examination in Respiratory System
Zhao Li, M.D.
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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

• Respiratory movement
• Abdominal breathing male adult and child
• Thoracic breathing female adult
• Respiratory rate 16-18 f/min
• Tachypnea gt20 f/min
• Bradypnea lt12 f/min
• 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

• 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 or pneumothorax
• Dullness
• Hydrothorax, atelectasis
• Flatness
• Massive Hydrothorax

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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
• Down emphysema
• Up atelectasis, intraabdominal pressure goes up

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4. Normal sound
s
6-8 cm

• 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 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

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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
• Tympanitic dullness (???)
• Decreased tension and gas 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

• Normal breath sound
• Abnormal breath sound
• Adventitious sound
• Vocal resonance (????)

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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
• Movement of thoracic wall
• Respiratory muscle weakness
• Obstruction of airway
• Hydrothorax or pneumothorax
• Abdominal diseases ascites, large tumor
• Increased
• Movement of respiration

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Abnormal vesicular breath sound (2)

• Prolonged expiration
• Bronchitis
• Asthma
• emphysema
• Cogwheel breath sound
• TB
• Pneumonia
• Coarse breath sound
• Early stage of bronchitis or pneumonia

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Abnormal bronchial breath sound (tubular breath
sound)

• Bronchial breath sound appears in supposed
  vesicular breath sound area
• 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 supposed
  vesicular breath sound area
• The lesion is relatively smaller or mixed with
  normal lung tissue

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3. Adventitious sound

• (moist) Crackles
• Rhonchi (wheezes)
• Pleural friction rub

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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

• Adventitious sound
• Intermittent
• Appeared in phase of inspiration or early
  expiration
• Constant in site
• Unchanged in character
• Medium and fine crackles exist meantime
• Less or disappeared after cough

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Classification of crackles

• According to intensity of the sound
• Loud moist crackles
• Slight moist crackles
• According to diameter of the airway crackles
  appeared
• Coarse trachea, main bronchi, or cavity
• Bronchiectasis, pulmo. edema, TB, lung abscess,
  coma
• Medium bronchi
• bronchitis, pneumonia
• Fine bronchioli
• pneumonia
• Crepitus
• Bronchiolitis, alveolitis, early pneumonia
  (pulmo. Congestion), elder subject, pat. bed
  rest for long time

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Site of crackles

• Local local lesion
• Pneumonia, TB, bronchiectasis
• Both bases
• Pulmo. edema, bronchopneumonia,
• chronic bronchitis
• Full fields
• Acute pulmo. edema, severe bronchopneumonia,
  chronic bronchitis with severe infection

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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

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Characteristics of rhonchi

• Adventitious sound
• High pitch
• Dominance in phase of expiration
• Variable intensity of character or site
• Wheezing

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Classification of rhonchi

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

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Site of rhonchi

• Both fields
• Asthma
• Chronic bronchitis
• Acute left heart failure
• Local site
• Tumor
• Endobronchial TB

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Pleural friction rub

• Cellulose exudation in pleurisy (rough pleura)
• Area of auscultation
• Anterolateral 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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Vocal resonance

• Bronchophony (?????)
• Consolidation
• Pectoriloqny (???)
• Massive consolidation
• Egophony (???)
• Upper area of hydrothorax
• Whispered (???)
• Consolidation

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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
• Inspection
• Decreased respiratory movement
• Palpation
• Increased vocal r

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Chronic bronchitis with emphysema
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Symptoms

• Chronic productive cough
• White mucous sputum or pus sputum (infection)
• Exertional dyspnea
• Breathlessness (dyspnea)
• Chest depression

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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)

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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

• 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

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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
• 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 pneumonia
• Progressive dyspnea
• Tyckycardia
• Cyanosis
• Respiratory failure

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Signs

• 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