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

Anterior imaginary lines and landmarks epigastric angle Infraclavicular fossa Anterior midline Suprasternal fossaSupraclavicular fossa Sternal line Parasternal line Midclavicular line

Lateral imaginary lines Anterior axillary line Midaxillary line Posterior axillary line

Posterior imaginary 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

Thoracic deformity Pectus excavatum Barrel chest Kyphosis

Inspection 1. Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult 2. Respiratory rate: f/min Tachypnea: >20 f/min Bradypnea: <12 f/min Shallow and fast  respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy Deep and fast  Agitation, intension Deep and slow  Severe metabolic acidosis (Kussmaul’s breathing)

Inspection 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

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

Percussion

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

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

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

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

4. Normal sound Border of lungs in percussion  Apex of lungs Kronig’s isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema  Anterior border absolute cardiac dullness area  Lower border 6 th, 8 th, 10 th intercostal space in midclavicular line, midaxillary line, scapular line, respectively Down: emphysema Up: atelectasis, intraabdominal pressure goes up

4. Normal sound s Shifting range of bottom of lung 6-8 cm  Shifting range of bottom of lung Along the scapular line Percussing bottom of lung, marking Asking the pat. to inspire deeply and hold Percussing bottom of lung, marking Asking the pat. to expire deeply and hold Percussing bottom of lung, marking Measuring the dist. between upper and lower lines Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphragmatic paralysis

5. Abnormal sound  Dullness, flatness, hyperresonance 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

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 ( 肺包虫 ) Pneumocystis ( 肺囊虫 ) Non-liquefied lung abscess  Others Hydrothorax Pleural thickness

5. Abnormal sound  Hyperresonance Emphysema  Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)  Amphorophony ( 空瓮音 ) Large and shallow cavity with smooth wall Tension pneumothorax  Tympanitic dullness ( 浊鼓音 ) Decreased tension and gas in alveoli  Atelectasis  Congestive or resolution stage of pneumonia  Pulmo. edema

5. Abnormal sound  Special areas on percussion in moderate hydrothorax Damoiseau’s curve Garland’s triangle area (tympanitic dullness) Grocco’s triangle area (dullness)

Auscultation

Order of auscultation

Sound of auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance ( 语音共振 )

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 Bronchovesicular Bronchial Bronchovesicular

2. Abnormal breath sound  Abnormal vesicular breath sound  Abnormal bronchial breath sound  Abnormal bronchovesicular breath sound

Abnormal vesicular breath sound(1) 1) Decreased or disappeared  Movement of thoracic wall  Respiratory muscle weakness  Obstruction of airway  Hydrothorax or pneumothorax  Abdominal diseases: ascites, large tumor 2) Increased  Movement of respiration

Abnormal vesicular breath sound (2) 3) Prolonged expiration  Bronchitis  Asthma  emphysema 4) Cogwheel breath sound  TB  Pneumonia 5) 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

3. Adventitious sound  (moist) Crackles  Rhonchi (wheezes)  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.

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

Classification of crackles  According to intensity of the sound 1. Loud moist crackles 2. Slight moist crackles  According to diameter of the airway crackles appeared 1. Coarse: trachea, main bronchi, or cavity  Bronchiectasis, pulmo. edema, TB, lung abscess, coma 2. Medium: bronchi  bronchitis, pneumonia 3. Fine: bronchioli  pneumonia 4. Crepitus:  Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time

Site of crackles 1. Local: local lesion Pneumonia, TB, bronchiectasis 2. Both bases Pulmo. edema, bronchopneumonia, chronic bronchitis 3. 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 1. Adventitious sound 2. High pitch 3. Dominance in phase of expiration 4. Variable intensity of character or site 5. Wheezing

Classification of rhonchi 1. Sibilant ( 高调 ) Bonchioli, bronchi 2. Sonorous ( 低调 ) Trachea, main bronchi

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

Pleural friction rub 1. Cellulose exudation in pleurisy (rough pleura) 2. Area of auscultation Anterolateral thoracic wall (maximal shifting area of lung) 3. Friction rub disappeared if holding breath 4. Friction rub appeared both breath and heart beat: mediastinal pleurisy 5. Causes Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma

Vocal resonance  Bronchophony ( 支气管语音） Consolidation  Pectoriloqny ( 胸语音 ) Massive consolidation  Egophony ( 羊语音 ) Upper area of hydrothorax  Whispered ( 耳语音 ) Consolidation

Main symptoms and signs in common respiratory diseases

Labor pneumonia

Symptoms  Chill  Continued fever: 39-40ºC  Chest pain  Tachypnea  Cough  Rusty sputum

Signs (1)  General signs Acute facial features, blushing Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lips

Signs (2)  Congestion  Inspection  Decreased respiratory movement  Palpation  Increased vocal r

Chronic bronchitis with emphysema

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

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)

Bronchial asthma

Symptom  Expiratory dyspnea with wheezing

Signs  Orthopnea  Cyanosis  Severe sweat  Decreased movement of respiration  Decreased vocal fremitus  Hyperresonance  Rhonchi in full fields of lungs

Hydrothorax (pleural effusion)

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

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

Pneumothorax

Symptoms  Sudden chest pain  Dyspnea  Forced sitting position  Unaffected side lying  Dry cough  Tension pneumonia Progressive dyspnea Tyckycardia Cyanosis Respiratory failure

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