Physical Examination in Respiratory System In the name of GOD Physical Examination in Respiratory System Hassan Ghobadi MD Assistant professor of Internal Medicine Ardabil University of Medical Science

Respiratory History Important to cover Occupational History, Allergies, Snoring, Daytime somnolence, Sexual history, Hobbies And Pets.

Respiratory Examination OBSERVATION (Closer inspection) -Fingernails Clubbing (cyanotic heart & lung diseases) Peripheral cyanosis Smoking stains -Wrists Hypertrophic Pulmonary Osteoarthropathy (HPOA) Count Respiratory Rate over one minute. Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged. Observe for use of accessory muscles (sternomastoids, abdominals).

Respiratory Examination OBSERVATION CONTINUED Face -Reddish (CO2 retention) -Bluish (cyanosis) Eyes -Horner’s Syndrome (ptosis, pupillary miosis and facial anhydrosis) Eyelids -erythema/scaling/pigmentation (allergies) Conjuctiva -pale (anaemia)

Respiratory Examination OBSERVATION CONTINUED Nose -Allergic crease -Nasal flaring (respiratory distress) Teeth -nicotine staining Lips/mucous membranes -cyanosis (central) -tonsils (enlarged, obstructing, pus)

Respiratory Examination OBSERVATION CONTINUED Trachea -midline, heaving, “tracheal tug” -vessel congestion Chest -barrel, pigeon, tunnel chest, paroxysmal breathing Abdomen -central obesity (OSA)

Respiratory Examination: PALPITATION Lymph nodes: - Cervical chain, post auricular, sub-mental, axillae Chest: - Anterior, Posterior and Axillae - Chest Expansion - Vocal resonance “99” – stethoscope - Vocal Fremitus “99” – hands

Respiratory Examination: PALPITATION CONTINUED Chest: - Whispering pectoriloquy - Ask the patient to whisper "ninety-nine" several times, auscultate several symmetrical areas over each lung, you should hear only faint sounds or nothing at all. If you can hear this clearly is suggests pneumonia - Increased fremitus, indicates fluid in the lung (consolidation). - Decreased fremitus, indicates sound transmission obstructed by chronic obstructive pulmonary disease (COPD), fluid outside the lung (pleural effusion), air outside the lung (pneumothorax), etc.

Respiratory Examination PERCUSSION - Side to side, top to bottom, comparing like with like - Dull to resonant Diaphragmatic excursion percuss to the level of dullness bilaterally, ask the patient to inspire deeply and percuss both sides again (should be 3-5 cm difference)

Respiratory Examination ASCULTATION - Comparing like with like, side to side, top to bottom - Breath sounds – vesicular (normal) to bronchial (fluid in airways eg pneumonia), increased or decreased, crackles (coarse, fine), wheeze Associated systems exam. - CVS (Corpulmonale)

Respiratory Examination 6MWD - 6 Minute Walk Distance ( Test ) MMRC - For evaluation of dyspnea severity

Chest wall Lines & Hallmarks

Anterior 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 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

Respiratory Examination INSPECTION PALPATION PERCUSSION AUSCULTATION

Inspection 1 - Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult 2 - Respiratory rate: 12 -18 f/min Tachypnea: > 18 f/min Bradypnea: < 12 f/min Shallow and fast respiratory muscular paralysis, pneumonia, pleurisy, elevated intra abdominal pressure, Deep and fast Agitation, intension Deep and slow Severe metabolic acidosis (Kussmaul’s breathing)

Inspection Continued 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

Thoracic deformity Kyphosis

Thoracic deformity Pectus excavatum

Thoracic deformity Barrel chest

Respiratory Examination INSPECTION PALPATION PERCUSSION AUSCULTATION

Palpation Thoracic expansion Vocal fremitus (tactil fremitus) 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, pulmonary embolism

Respiratory Examination INSPECTION PALPATION PERCUSSION AUSCULTATION

Percussion 1- Method Order: Pleximeter: distal inter-phalangeal joint of left middle finger Plexor: right middle finger tip Order: Up to down, anterior to posterior

Percussion 2. Affected factors Thickness of thoracic wall Calcification of costal cartilage Hydrothorax Containing gas in alveoli Alveolar tension Alveolar elasticity

Percussion 3. Classification Resonance Hyperresonance Tympany Dullness Normal Hyperresonance Emphysema Tympany Cavity or pneumothorax Dullness Hydrothorax, atelectasis Flatness Massive Hydrothorax

Percussion 4. Normal sound Lung’s sound in percussion Resonance Slight dullness in some areas (upper, back) due to thickness of muscles and skeletons

Respiratory Examination INSPECTION PALPATION PERCUSSION AUSCULTATION

Order of auscultation

Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance

Normal sound Border of lungs in percussion Apex of lungs 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

1. Normal breath sound Tracheal breath sound Bronchial breath sound Bronchovesicular 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 Bronchovesicular Bronchial

Shifting range of bottom of lung Normal sound Decreased: Emphysema, Atelactasis, Fibrosis, Pulmonary edema, Pneumonia Detected impossibly: Pleura adhesion, Massive hydrothorax, Pneumothorax, Diaphragmatic paralysis Shifting range of bottom of lung 6-8 cm

Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance

Abnormal sound The depth of the lesion > 5 cm Dullness, flatness, hyper resonance 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

Abnormal sound Dullness or flatness Decreased containing gas in alveoli Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. Fibrosis No gas in alveoli Tumor Pulmonary Hydatid Pneumocystis Non-liquefied lung abscess Others Hydrothorax Pleural thickness

Abnormal sound Hyperresonance Tympany Dullness Emphysem Pneumothorax Large cavity (TB, lung abscess, lung cyst) Dullness Decreased tension and gas in alveoli Atelectasis Congestive or resolution stage of pneumonia Pulmonary edema

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

Abnormal vesicular breath sound (2) Prolonged expiration Bronchitis Asthma emphysema Cog-wheel breath sound TB Pneumonia Coarse breath sound Early stage of bronchitis or pneumonia

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

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

Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance

Adventitious sound Crackles ( fine, coarse ) wheezes Rhonchi Pleural friction rub

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.

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

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

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

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

Site of rhonchi 1- Both fields Asthma Chronic bronchitis Acute left heart failure 2- Local site Tumor Endobronchial TB

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

Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance

Vocal resonance Bronchophony Pectoriloqny Egophony Whispered Consolidation Pectoriloqny Massive consolidation Egophony Upper area of hydrothorax Whispered

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