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CLINICAL EXAMINATION
OF THE
RESPIRATORY SYSTEM
By,
Dr.Prajwal
Clinical Examination of RS
Different Lines
Vertebra prominence
Sternal angle and ICS
Suprasternal Notch
Sternal Angle
1. 2nd Rib joins
2. Arch of Aorta(beginning and
the end)
3. Trachea bifurcates into the
two bronchi
4. Pulmonary trunk bifurcation
5. Left recurrent laryngeal nerve
looping under the arch of the
aorta
6. Azygous Vein draining into
the superior vena cava.
7. Thoracic duct emptying into
the left subclavian vein
Clinical Examination of RS
Lung fissure and Borders
Lung fissure and Borders
Oblique fissure (Major interlobar fissure)
Horizontal fissure (Minor interlobar fissure)
T2
EXAMINATION OF THE
RESPIRATORY SYSTEM
1) General Examination (RS)
2) Examination of the Chest
Upper Respiratory Tract Lower Respiratory Tract
1)General Examination
Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenopathy
Temperature
Pulse
Respiratory Rate
BP
JVP
Pallor (Anemia)
The pallor of anemia is best seen in the
mucous membranes of the conjunctivae, lips
and tongue and in the nail beds
Anaemia may occur when there is
a. Haemoptysis
b. Excessive sputum production and protein
loss
c. Loss of appetite leading to malnutrition
Cyanosis
This is a blue discoloration of the skin and mucous membranes caused
by increased concentration of reduced hemoglobin (5g/dl)
Central cyanosis may result from the reduced arterial oxygen saturation
caused by cardiac or pulmonary disease. Intracardiac or extracardiac
shunting.
Impaired pulmonary function
a. Alveolar hypoventilation
b. Ventilation—Perfusion mismatch
c. Impaired oxygen diffusion.
Bulbous enlargement of the distal portion
of the digit due to increased subungual soft
tissue.
Clubbing
Grading of Clubbing
Grade I Positive nail bed fluctuation
Grade II Obliteration of the Lovibond angle
Grade III Parrot beak / Drumstick appearance
Grade IV Hypertrophic osteoarthropathy.
Pulmonary and Thoracic Causes
a. Bronchogenic carcinoma (rare in adenocarcinoma)
b. Metastatic lung cancer
c. Suppurative lung disease
1. Bronchiectasis
2. Cystic fibrosis
3. Lung abscess
4. Empyema
d. Interstitial lung disease
e. Longstanding pulmonary tuberculosis
f. Chronic bronchitis
g. Mesothelioma
h. Neurogenic diaphragmatic tumour
i. Pulmonary AV malformation
j. Sarcoidosis.
Hypertrophic Osteoarthropathy
It is a painful swelling of the wrist, elbow, knee, ankle,
with radiographic evidence of sub-periosteal new bone
formation. It can be familial or idiopathic.
common disorders that can produce it are:
a. Bronchogenic carcinoma
b. Cystic fibrosis
c. Neurofibroma
d. A-V malformation.
Lymphadenopathy
Scalene lymph node enlargement
1. Large and fixed in secondary involvement from a
primary lung malignancy
2. Hard and craggy, matted, with or without sinus
formation in healed and calcified tuberculous
lymphadenopathy.
Blood Pressure
Pulsus Paradoxus
 Systolic blood pressure normally falls during quiet inspiration in
normal individuals.
 Pulsus paradoxus is defined as a fall of systolic blood pressure of
>10 mmHg during the inspiratory phase.
 severe acute asthma or exacerbations of chronic obstructive
pulmonary disease.
Examination of the Neck Veins
Jugular Venous Pulse
COPD/cor pulmonale
Bilateral non-pulsatile
SVC obstruction
Massive right sided pleural effusion
2) Examination of the Chest
 Inspection
 Palpation
 Percussion
 Auscultation
The subject should be examined in the Standing or Sitting position in an
erect, and in good light.
All the findings in the clinical examination should
be compared on both sides in the following areas:
1. Supraclavicular area
2. Infraclavicular area
3. Mammary region
4. Inframammary region
5. Axillary region
6. Infra-axillary region
7. Suprascapular region
8. Interscapular region
9. Infrascapular region.
Inspection
 Inspection for Position of trachea
 Inspection for Symmetry of Chest
 Inspection for Chest wall abnormalities
 Inspection for Movement of the Chest
 Inspection for Apex beat
 Inspection for Dilated and engorged veins
 Inspection for Surgical or any Scars or Sinuses
Inspection for Position of trachea
Trail’s sign: It is the undue prominence of the clavicular head of
sternomastoid on the side to which the trachea is deviated.
Position of Apex Beat
The apex beat is shifted to the side of mediastinal shift.
Inspection for Symmetry of Chest
 Normal chest is symmetrical and elliptical in cross section.
The normal antero-posterior to transverse diameter ratio
(Hutchinson’s index) is 5 : 7.
 The normal subcostal angle is 90°. It is more acute in
males than in females.
AP
T
AP:T = 5:7
Look for the following:
1. Drooping of the shoulder
2. Hollowness or fullness in the supraclavicular and infraclavicular fossa
3. Crowding of ribs
4. Kyphosis (forward bending of the spine)
5. Scoliosis (lateral bending of the spine).
Inspection for Chest wall abnormalities
1.Flat chest: The antero-posterior to transverse diameter ratio is 1 :
2.
Seen in pulmonary TB and fibrothorax
2.Barrel chest: The anteroposterior to transverse diameter
ratio is 1 : 1.
Seen in physiological states like infancy and old age and in
pathological states like COPD (emphysema)
3. Pigeon chest (Pectus carinatum) : It is forward protrusion of
sternum and adjacent costal cartilage,
seen in Marfan’s syndrome, in childhood asthma and rickets
4.Pectus excavatum (funnel chest, cobbler’s chest)
It is the exaggeration of the normal hollowness over the
lower end of the sternum. It is a developmental defect.
The apex beat shifted further to the left and the ventilatory
capacity of the lung is restricted.
It is seen in Marfan’s syndrome
5. Harrison’s sulcus: It is due to the indrawing of ribs to form
symmetrical horizontal grooves above the costal margin, along the line of
attachment of diaphragm
occurs in chronic respiratory
disease in childhood,
childhood asthma, rickets and
blocked nasopharynx due to
adenoid enlargement
6. Scorbutic rosary: It is the sharp
angulation, with or without beading or
rosary formation, of the ribs, arising as
a result of backward displacement or
pushing in of the sternum,
e.g. Vitamin C deficiency.
7. Rickety rosary: It is a bead like
enlargement of costochondral junction,
e.g. rickets
Clinical Examination of RS
Spinal Deformity
Kyphoscoliosis : It is a disfiguring or
disabling deformity of the spine, producing a
shift of the apex beat. It reduces the
ventilatory capacity of the lung and
increases the work of breathing.
Inspection for Movement of the Chest
It is described in terms of rate, rhythm, equality and type of breathing
Rate
• The normal respiratory rate in relaxed adults is 14-18
breaths per minute
• The type of breathing in women is thoraco-abdominal
and in men is abdomino-thoracic
• The ratio of pulse rate to respiratory rate is 4 : 1.
Tachypnoea: It is an increase in respiratory rate more
than 20 per minute(Adult). Conditions causing tachypnoea
are:
a. Nervousness
b. Exertion
c. Fever
d. Hypoxia
e. Respiratory conditions
i. Acute pulmonary oedema
ii. Pneumonia
iii. Pulmonary embolism
iv. ARDS
v. Metabolic acidosis
Bradypnoea: It is a decrease in the rate of respiration.
Conditions causing bradypnoea are:
a. Alkalosis
b. Hypothyroidism (myxoedema)
c. Narcotic drug poisoning
d. Raised intracranial tension.
Hyperpnoea: It is an increase in depth of respiration.
Conditions causing hyperpnoea are:
a. Acidosis
b. Brainstem lesion
c. Hysteria.
Rhythm
Inspiration: It is an active process brought about by the
contraction of the external intercostal muscles and the
diaphragm
Expiration: It is a passive process and it depends upon
elastic recoil of the lungs.
Accessory muscles of inspiration are the scaleni,
trapezius and pectoral muscles.
Accessory muscles of expiration are abdominal
muscles and latissimus dorsi.
Abnormal Breathing Patterns
Abnormal breathing patterns may be regular or irregular
Regular abnormal breathing patterns
a. Cheyne-Stokes breathing: It is characterised by hyperpnoea
followed by apnoea.
It occurs in cardiac failure, renal failure, narcotic drug
poisoning and raised intracranial pressure
b. Kussmaul’s breathing: It is characterised by increase in rate and
depth of breathing.
It occurs in metabolic acidosis and pontine lesions.
Irregular abnormal breathing patterns
a. Biots breathing: It is characterised by apnoea between several
shallow or few deep inspirations. It occurs in meningitis
b. Ataxic breathing: It is characterised by irregular pattern of
breathing where both deep and shallow breaths occur randomly. It
occurs in brainstem lesions
c. Apneustic breathing: It is characterised by pause at
full inspiration, alternating with a pause in expiration,
lasting for 2 to 3 seconds. It occurs in pontine
lesions
Palpation
 Palpation for Apex Beat (Position and Character)
 Palpation for Position of trachea
 Palpation for Measurement of the Chest Expansion
 Palpation for Assessing of Chest Expansion
 Palpation for Vocal fremitus (VF)
 Palpation for Direction of flow in veins
 Palpation for Tender points
The position of the trachea is confirmed by slightly flexing the neck
so that the chin remains in the midline.
The index finger is then inserted in the suprasternal notch and the
tracheal ring is felt.
Slight shift of trachea to the right is normal
Palpation for Position of trachea
Clinical Examination of RS
Clinical Examination of RS
Measurement of the Chest Expansion
The expansion of the chest should be measured with a tape
measure placed around the chest just below the level of the
nipples/inferior angle of scapula.
 Chest circumference in full expiration
 Chest circumference at full inspiration
 Chest expansion
 Right/Left Hemithorax
Normal expansion of the chest is 5-8 cm
In severe emphysema, it is less than 1 cm
General Restriction of Expansion
a. COPD
b. Extensive bilateral disease
c. Ankylosing spondylitis
d. Interstitial lung disease
e. Systemic sclerosis (hide bound chest).
Asymmetrical Expansion of the Chest
a. Pleural effusion
b. Pneumothorax
c. Extensive consolidation
d. Collapse
e. Fibrosis.
In all these above conditions, diminished
expansion occurs on the affected side.
Assessing Symmetry of Chest Expansion
anterior thoracic expansion
upper thoracic expansion
posterior thoracic expantion
Clinical Examination of RS
 It is a vibration felt by the hand when the patient is
asked to repeat ninety-nine or one-one-one, by putting
the vocal cord into action.
 Identical areas of the chest are compared on both sides.
 It is felt with the flat of the hand or with the ulnar
border of the hand for accurate localization.
 It is increased in consolidation.
 It is decreased in pleural effusion
Palpation for Vocal fremitus (VF)
Tenderness over the Chest Wall
It may be due to:
1. Empyema
2. Local inflammation of parietal pleura, soft tissue and
osteomyelitis
3. Infiltration with tumor
4. Non-respiratory cause (amoebic liver abscess).
Percussion
 Percussion for the Lung fields
Cardinal Rules of Percussion
a. The pleximeter: The middle finger of the examiner’s left hand should
be opposed tightly over the chest wall, over the intercostal spaces. The
other fingers should not touch the chest wall. Greater pressure should be
applied over a thick chest wall to remove air pockets
b. The plexor: The middle or the index finger of the examiner’s right
hand is used to hit the middle phalanx of the pleximeter
c. The percussion movement should be sudden, originating from the
wrist. The finger should be removed immediately after striking to avoid
damping
d. Proceed from the area of normal resonance to the area of impaired or
dull note, as the difference is then easily appreciated
e. The long axis of the pleximeter is kept parallel to the border of the
organ to be percussed.
Direct percussion—clavicle
Anterior Chest Wall
Clavicle: Direct percussion is used and percussion is
done within the medial 1/3rd of the clavicle
Supraclavicular region (Kronig’s isthumus):
It is a band of resonance 5-7 cm size over the
Supraclavicular fossa. The percussion is done by
standing behind the patient and the resonance of the
lung apices is assessed by this method.
Second to sixth intercostal spaces. However, the percussion
note cannot be compared due to relative cardiac dullness on
the left side.
Liver dullness can be percussed from the right 5th rib
downwards in the midclavicular line.
Lateral Chest Wall
Fourth to seventh intercostal spaces.
Liver dullness can be percussed from the right 8th rib
downwards in the midaxillary line.
Posterior Chest Wall
a. Suprascapular (above the spine of the scapula)
b. Interscapular region
c. Infrascapular region up to the eleventh rib.
Liver dullness can be percussed from the right 10th rib
downwards in the midscapular line.
Clinical Examination of RS
Clinical Examination of RS
Tidal Percussion
 This is done to differentiate upward enlargement of liver or
subdiaphragmatic abscess from right sided parenchymal or pleural
disorder.
 If on deep inspiration, the previous dull note in the fifth right
intercostal space on the mid clavicular line becomes resonant, it
indicates that the dullness was due to the liver, which had been
pushed down by the right hemidiaphragm with deep inspiration.
 If the dullness persists on the other hand, it indicates underlying
right sided parenchymal or pleural pathology, in the absence of
diaphragmatic paralysis.
Shifting Dullness
This is done to demonstrate the shift of fluid in hydropneumothorax.
The immediate shift of fluid can be demonstrated by the dull area
percussed in the axilla in the sitting posture, becoming resonant on
lying down on the healthy side.
Auscultation
 Auscultation for Breath Sounds
 Auscultation for Vocal Resonance
Listen with the patient relaxed and breathing deeply
through his open mouth.
Auscultate each side alternately, comparing findings over a
large number of equivalent positions to ensure that you do
not miss localised abnormalities.
Listen:
■ anteriorly from above the clavicle down to the sixth rib
■ laterally from the axilla to the eighth rib
■ posteriorly down to the level of the 11th rib.
■ Assess the quality and amplitude of the breath sounds.
Identifyany gap between inspiration and expiration, and
listen for added sounds.
Avoid auscultation within 3 cm of the midline anteriorly or
posteriorly, as these areas may transmit soundsdirectly from
the trachea or main bronchi.
Vesicular breath sounds
 low pitched, rustling in
nature
 produced by attenuating and
filtering effect of the lung
parenchyma.
 Duration of the inspiratory
phase is longer than the
expiratory phase in a ratio of
3 : 1.
 There is no pause between
the end of inspiration and the
beginning of expiration.
Bronchial breath sounds
 It is loud and high pitched,
with an aspirate or guttural
quality.
 It is produced by passage of
air through the trachea and
large bronchi
 The duration of inspiration is
shortened whereas that of
expiration is prolonged or
equal
 There is a pause between
inspiration and expiration.
Clinical Examination of RS
Clinical Examination of RS
Types of Bronchial Breathing
a. Tubular
b. Cavernous
c. Amphoric.
Added sounds
Added sounds are abnormal sounds that arise in the lung itself or in the
pleura.
The added sounds most commonly arising in the lung are best referred
to as wheezes and crackles.
Pleural rub is a “creaking” or “rubbing” sound produced by friction
between the two layers of inflamed and roughened pleura.
NEW Terms OLD Terms Definations
coarse crackles râles non-musical, interruptedshort,
explosive sounds often described as
bubbling or clicking.
fine crackles crepitations
wheezes rhonchi Continuous musical sounds
associated with airway narrowing.
Vocal resonance is the detection of vibrations transmitted to the
chest from the vocal cords as the patient repeats a phrase, usually the
words ‘ninetynine’
assess the quality and amplitude of vocal resonance.
Types
a. Bronchophony: Voice sounds appear to be heard near the earpiece
of stethoscope and words are unclear, e.g. consolidation, cavity
communicating with a bronchus,
b. Aegophony: Voice sound has a nasal or bleating quality. On saying
‘E’, it will be heard as ‘A’ (E to A sign),
e.g. consolidation, cavity.
c. Whispering pectoriloquy: The patient is asked to whisper words at
the end of expiration, and this whispered voice individual syllables
are recognised clearly,
e.g. pneumonic consolidation, cavity communicating with a bronchus
Examination of RSName:
Age:
Sex:
Address:
Occupation:
1) General Physical Examination:
Young patient moderately built and moderately nourished, well oriented to
time place and person, conscious and cooperative
Pallor
Icterus
Cyanosis
Clubbing
Edema
Lymphadenopathy
Temperature
Pulse
Respiratory Rate
BP
JVP
3) Examination of the Chest
Inspection:
 Trachea appears Central in Position
 Shape of the chest is elliptical, Bilaterally symmetrical
 Movement of the chest is equal on both sides and normal
 Respiratory Movement
 Rate : 14 – 18 Breaths per minute
 Rhythm : Regular
 Depth : Normal
 Type : Abdominothoracic / Thoracoabdominal
 Accessory muscles of Respiration not in use
 No skeletal deformity seen
 Apical impulse not seen/seen at Left 5th ICS medial to MCL
 No dilated or engorged veins present
 No scars or swelling or other visible pulsations seen
Palpation:
 Apical Impulse felt at Left 5th ICS medial to MCL and is of
Normal Character
 Trachea centrally Placed (slightly deviated to right side)
 Expansion of the chest is normal and symmetrical, expansion
is more at the base compared to apex and sides of chest
 Measurement of the Chest Expansion
 Transverse Diameter : ___cm
 Anteroposterior Diameter : ___cm
 Right/Left Hemithorax : ___cm
 Chest circumference in expiration : ___cm
 Chest circumference at full inspiration: ___cm
 Chest expansion : ___cm
 No tenderness present
Area Right Left
Supraclavicular area Equal on both sides
Infraclavicular area Equal on both sides
Mammary region Equal on both sides
Inframammary region Equal on both sides
Axillary region Equal on both sides
Infra-axillary region Equal on both sides
Suprascapular region Equal on both sides
Interscapular region Equal on both sides
Infrascapular region Equal on both sides
 Vocal fremitus (VF)
Percussion:
Area Right Left
Supraclavicular area Resonant Resonant
Infraclavicular area Resonant Resonant
Mammary region Resonant Dullness
Inframammary region Dullness(5th ICS onwards) Dullness
Axillary region Resonant Resonant
Infra-axillary region Resonant Resonant
Suprascapular region Resonant Resonant
Interscapular region Resonant Resonant
Infrascapular region Resonant Resonant
Auscultation
 Breath Sounds
Area Right Left
Supraclavicular area Vesicular Vesicular
Infraclavicular area Vesicular Vesicular
Mammary region Vesicular Vesicular
Inframammary region Vesicular Vesicular
Axillary region Vesicular Vesicular
Infra-axillary region Vesicular Vesicular
Suprascapular region Vesicular Vesicular
Interscapular region Vesicular Vesicular
Infrascapular region Vesicular Vesicular
 No added Sounds
Area Right Left
Supraclavicular area Equal on both sides
Infraclavicular area Equal on both sides
Mammary region Equal on both sides
Inframammary region Equal on both sides
Axillary region Equal on both sides
Infra-axillary region Equal on both sides
Suprascapular region Equal on both sides
Interscapular region Equal on both sides
Infrascapular region Equal on both sides
 Vocal Resonance (VR)
Report: Examination of the respiratory system of the subject is clinically normal

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Clinical Examination of RS

  • 5. Sternal angle and ICS Suprasternal Notch Sternal Angle
  • 6. 1. 2nd Rib joins 2. Arch of Aorta(beginning and the end) 3. Trachea bifurcates into the two bronchi 4. Pulmonary trunk bifurcation 5. Left recurrent laryngeal nerve looping under the arch of the aorta 6. Azygous Vein draining into the superior vena cava. 7. Thoracic duct emptying into the left subclavian vein
  • 9. Lung fissure and Borders Oblique fissure (Major interlobar fissure) Horizontal fissure (Minor interlobar fissure) T2
  • 10. EXAMINATION OF THE RESPIRATORY SYSTEM 1) General Examination (RS) 2) Examination of the Chest Upper Respiratory Tract Lower Respiratory Tract
  • 12. Pallor (Anemia) The pallor of anemia is best seen in the mucous membranes of the conjunctivae, lips and tongue and in the nail beds Anaemia may occur when there is a. Haemoptysis b. Excessive sputum production and protein loss c. Loss of appetite leading to malnutrition
  • 13. Cyanosis This is a blue discoloration of the skin and mucous membranes caused by increased concentration of reduced hemoglobin (5g/dl) Central cyanosis may result from the reduced arterial oxygen saturation caused by cardiac or pulmonary disease. Intracardiac or extracardiac shunting. Impaired pulmonary function a. Alveolar hypoventilation b. Ventilation—Perfusion mismatch c. Impaired oxygen diffusion.
  • 14. Bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue. Clubbing
  • 15. Grading of Clubbing Grade I Positive nail bed fluctuation Grade II Obliteration of the Lovibond angle Grade III Parrot beak / Drumstick appearance Grade IV Hypertrophic osteoarthropathy.
  • 16. Pulmonary and Thoracic Causes a. Bronchogenic carcinoma (rare in adenocarcinoma) b. Metastatic lung cancer c. Suppurative lung disease 1. Bronchiectasis 2. Cystic fibrosis 3. Lung abscess 4. Empyema d. Interstitial lung disease e. Longstanding pulmonary tuberculosis f. Chronic bronchitis g. Mesothelioma h. Neurogenic diaphragmatic tumour i. Pulmonary AV malformation j. Sarcoidosis.
  • 17. Hypertrophic Osteoarthropathy It is a painful swelling of the wrist, elbow, knee, ankle, with radiographic evidence of sub-periosteal new bone formation. It can be familial or idiopathic. common disorders that can produce it are: a. Bronchogenic carcinoma b. Cystic fibrosis c. Neurofibroma d. A-V malformation.
  • 18. Lymphadenopathy Scalene lymph node enlargement 1. Large and fixed in secondary involvement from a primary lung malignancy 2. Hard and craggy, matted, with or without sinus formation in healed and calcified tuberculous lymphadenopathy.
  • 19. Blood Pressure Pulsus Paradoxus  Systolic blood pressure normally falls during quiet inspiration in normal individuals.  Pulsus paradoxus is defined as a fall of systolic blood pressure of >10 mmHg during the inspiratory phase.  severe acute asthma or exacerbations of chronic obstructive pulmonary disease.
  • 20. Examination of the Neck Veins Jugular Venous Pulse COPD/cor pulmonale Bilateral non-pulsatile SVC obstruction Massive right sided pleural effusion
  • 21. 2) Examination of the Chest  Inspection  Palpation  Percussion  Auscultation The subject should be examined in the Standing or Sitting position in an erect, and in good light.
  • 22. All the findings in the clinical examination should be compared on both sides in the following areas: 1. Supraclavicular area 2. Infraclavicular area 3. Mammary region 4. Inframammary region 5. Axillary region 6. Infra-axillary region 7. Suprascapular region 8. Interscapular region 9. Infrascapular region.
  • 23. Inspection  Inspection for Position of trachea  Inspection for Symmetry of Chest  Inspection for Chest wall abnormalities  Inspection for Movement of the Chest  Inspection for Apex beat  Inspection for Dilated and engorged veins  Inspection for Surgical or any Scars or Sinuses
  • 24. Inspection for Position of trachea Trail’s sign: It is the undue prominence of the clavicular head of sternomastoid on the side to which the trachea is deviated. Position of Apex Beat The apex beat is shifted to the side of mediastinal shift.
  • 25. Inspection for Symmetry of Chest  Normal chest is symmetrical and elliptical in cross section. The normal antero-posterior to transverse diameter ratio (Hutchinson’s index) is 5 : 7.  The normal subcostal angle is 90°. It is more acute in males than in females. AP T AP:T = 5:7
  • 26. Look for the following: 1. Drooping of the shoulder 2. Hollowness or fullness in the supraclavicular and infraclavicular fossa 3. Crowding of ribs 4. Kyphosis (forward bending of the spine) 5. Scoliosis (lateral bending of the spine).
  • 27. Inspection for Chest wall abnormalities 1.Flat chest: The antero-posterior to transverse diameter ratio is 1 : 2. Seen in pulmonary TB and fibrothorax
  • 28. 2.Barrel chest: The anteroposterior to transverse diameter ratio is 1 : 1. Seen in physiological states like infancy and old age and in pathological states like COPD (emphysema)
  • 29. 3. Pigeon chest (Pectus carinatum) : It is forward protrusion of sternum and adjacent costal cartilage, seen in Marfan’s syndrome, in childhood asthma and rickets
  • 30. 4.Pectus excavatum (funnel chest, cobbler’s chest) It is the exaggeration of the normal hollowness over the lower end of the sternum. It is a developmental defect. The apex beat shifted further to the left and the ventilatory capacity of the lung is restricted. It is seen in Marfan’s syndrome
  • 31. 5. Harrison’s sulcus: It is due to the indrawing of ribs to form symmetrical horizontal grooves above the costal margin, along the line of attachment of diaphragm occurs in chronic respiratory disease in childhood, childhood asthma, rickets and blocked nasopharynx due to adenoid enlargement
  • 32. 6. Scorbutic rosary: It is the sharp angulation, with or without beading or rosary formation, of the ribs, arising as a result of backward displacement or pushing in of the sternum, e.g. Vitamin C deficiency. 7. Rickety rosary: It is a bead like enlargement of costochondral junction, e.g. rickets
  • 34. Spinal Deformity Kyphoscoliosis : It is a disfiguring or disabling deformity of the spine, producing a shift of the apex beat. It reduces the ventilatory capacity of the lung and increases the work of breathing.
  • 35. Inspection for Movement of the Chest It is described in terms of rate, rhythm, equality and type of breathing Rate • The normal respiratory rate in relaxed adults is 14-18 breaths per minute • The type of breathing in women is thoraco-abdominal and in men is abdomino-thoracic • The ratio of pulse rate to respiratory rate is 4 : 1.
  • 36. Tachypnoea: It is an increase in respiratory rate more than 20 per minute(Adult). Conditions causing tachypnoea are: a. Nervousness b. Exertion c. Fever d. Hypoxia e. Respiratory conditions i. Acute pulmonary oedema ii. Pneumonia iii. Pulmonary embolism iv. ARDS v. Metabolic acidosis
  • 37. Bradypnoea: It is a decrease in the rate of respiration. Conditions causing bradypnoea are: a. Alkalosis b. Hypothyroidism (myxoedema) c. Narcotic drug poisoning d. Raised intracranial tension. Hyperpnoea: It is an increase in depth of respiration. Conditions causing hyperpnoea are: a. Acidosis b. Brainstem lesion c. Hysteria.
  • 38. Rhythm Inspiration: It is an active process brought about by the contraction of the external intercostal muscles and the diaphragm Expiration: It is a passive process and it depends upon elastic recoil of the lungs. Accessory muscles of inspiration are the scaleni, trapezius and pectoral muscles. Accessory muscles of expiration are abdominal muscles and latissimus dorsi.
  • 39. Abnormal Breathing Patterns Abnormal breathing patterns may be regular or irregular Regular abnormal breathing patterns a. Cheyne-Stokes breathing: It is characterised by hyperpnoea followed by apnoea. It occurs in cardiac failure, renal failure, narcotic drug poisoning and raised intracranial pressure b. Kussmaul’s breathing: It is characterised by increase in rate and depth of breathing. It occurs in metabolic acidosis and pontine lesions.
  • 40. Irregular abnormal breathing patterns a. Biots breathing: It is characterised by apnoea between several shallow or few deep inspirations. It occurs in meningitis b. Ataxic breathing: It is characterised by irregular pattern of breathing where both deep and shallow breaths occur randomly. It occurs in brainstem lesions c. Apneustic breathing: It is characterised by pause at full inspiration, alternating with a pause in expiration, lasting for 2 to 3 seconds. It occurs in pontine lesions
  • 41. Palpation  Palpation for Apex Beat (Position and Character)  Palpation for Position of trachea  Palpation for Measurement of the Chest Expansion  Palpation for Assessing of Chest Expansion  Palpation for Vocal fremitus (VF)  Palpation for Direction of flow in veins  Palpation for Tender points
  • 42. The position of the trachea is confirmed by slightly flexing the neck so that the chin remains in the midline. The index finger is then inserted in the suprasternal notch and the tracheal ring is felt. Slight shift of trachea to the right is normal Palpation for Position of trachea
  • 45. Measurement of the Chest Expansion The expansion of the chest should be measured with a tape measure placed around the chest just below the level of the nipples/inferior angle of scapula.  Chest circumference in full expiration  Chest circumference at full inspiration  Chest expansion  Right/Left Hemithorax Normal expansion of the chest is 5-8 cm In severe emphysema, it is less than 1 cm
  • 46. General Restriction of Expansion a. COPD b. Extensive bilateral disease c. Ankylosing spondylitis d. Interstitial lung disease e. Systemic sclerosis (hide bound chest). Asymmetrical Expansion of the Chest a. Pleural effusion b. Pneumothorax c. Extensive consolidation d. Collapse e. Fibrosis. In all these above conditions, diminished expansion occurs on the affected side.
  • 47. Assessing Symmetry of Chest Expansion anterior thoracic expansion upper thoracic expansion posterior thoracic expantion
  • 49.  It is a vibration felt by the hand when the patient is asked to repeat ninety-nine or one-one-one, by putting the vocal cord into action.  Identical areas of the chest are compared on both sides.  It is felt with the flat of the hand or with the ulnar border of the hand for accurate localization.  It is increased in consolidation.  It is decreased in pleural effusion Palpation for Vocal fremitus (VF)
  • 50. Tenderness over the Chest Wall It may be due to: 1. Empyema 2. Local inflammation of parietal pleura, soft tissue and osteomyelitis 3. Infiltration with tumor 4. Non-respiratory cause (amoebic liver abscess).
  • 51. Percussion  Percussion for the Lung fields
  • 52. Cardinal Rules of Percussion a. The pleximeter: The middle finger of the examiner’s left hand should be opposed tightly over the chest wall, over the intercostal spaces. The other fingers should not touch the chest wall. Greater pressure should be applied over a thick chest wall to remove air pockets b. The plexor: The middle or the index finger of the examiner’s right hand is used to hit the middle phalanx of the pleximeter c. The percussion movement should be sudden, originating from the wrist. The finger should be removed immediately after striking to avoid damping d. Proceed from the area of normal resonance to the area of impaired or dull note, as the difference is then easily appreciated e. The long axis of the pleximeter is kept parallel to the border of the organ to be percussed.
  • 53. Direct percussion—clavicle Anterior Chest Wall Clavicle: Direct percussion is used and percussion is done within the medial 1/3rd of the clavicle Supraclavicular region (Kronig’s isthumus): It is a band of resonance 5-7 cm size over the Supraclavicular fossa. The percussion is done by standing behind the patient and the resonance of the lung apices is assessed by this method. Second to sixth intercostal spaces. However, the percussion note cannot be compared due to relative cardiac dullness on the left side. Liver dullness can be percussed from the right 5th rib downwards in the midclavicular line.
  • 54. Lateral Chest Wall Fourth to seventh intercostal spaces. Liver dullness can be percussed from the right 8th rib downwards in the midaxillary line. Posterior Chest Wall a. Suprascapular (above the spine of the scapula) b. Interscapular region c. Infrascapular region up to the eleventh rib. Liver dullness can be percussed from the right 10th rib downwards in the midscapular line.
  • 57. Tidal Percussion  This is done to differentiate upward enlargement of liver or subdiaphragmatic abscess from right sided parenchymal or pleural disorder.  If on deep inspiration, the previous dull note in the fifth right intercostal space on the mid clavicular line becomes resonant, it indicates that the dullness was due to the liver, which had been pushed down by the right hemidiaphragm with deep inspiration.  If the dullness persists on the other hand, it indicates underlying right sided parenchymal or pleural pathology, in the absence of diaphragmatic paralysis. Shifting Dullness This is done to demonstrate the shift of fluid in hydropneumothorax. The immediate shift of fluid can be demonstrated by the dull area percussed in the axilla in the sitting posture, becoming resonant on lying down on the healthy side.
  • 58. Auscultation  Auscultation for Breath Sounds  Auscultation for Vocal Resonance
  • 59. Listen with the patient relaxed and breathing deeply through his open mouth. Auscultate each side alternately, comparing findings over a large number of equivalent positions to ensure that you do not miss localised abnormalities. Listen: ■ anteriorly from above the clavicle down to the sixth rib ■ laterally from the axilla to the eighth rib ■ posteriorly down to the level of the 11th rib. ■ Assess the quality and amplitude of the breath sounds. Identifyany gap between inspiration and expiration, and listen for added sounds. Avoid auscultation within 3 cm of the midline anteriorly or posteriorly, as these areas may transmit soundsdirectly from the trachea or main bronchi.
  • 60. Vesicular breath sounds  low pitched, rustling in nature  produced by attenuating and filtering effect of the lung parenchyma.  Duration of the inspiratory phase is longer than the expiratory phase in a ratio of 3 : 1.  There is no pause between the end of inspiration and the beginning of expiration. Bronchial breath sounds  It is loud and high pitched, with an aspirate or guttural quality.  It is produced by passage of air through the trachea and large bronchi  The duration of inspiration is shortened whereas that of expiration is prolonged or equal  There is a pause between inspiration and expiration.
  • 63. Types of Bronchial Breathing a. Tubular b. Cavernous c. Amphoric.
  • 64. Added sounds Added sounds are abnormal sounds that arise in the lung itself or in the pleura. The added sounds most commonly arising in the lung are best referred to as wheezes and crackles. Pleural rub is a “creaking” or “rubbing” sound produced by friction between the two layers of inflamed and roughened pleura. NEW Terms OLD Terms Definations coarse crackles râles non-musical, interruptedshort, explosive sounds often described as bubbling or clicking. fine crackles crepitations wheezes rhonchi Continuous musical sounds associated with airway narrowing.
  • 65. Vocal resonance is the detection of vibrations transmitted to the chest from the vocal cords as the patient repeats a phrase, usually the words ‘ninetynine’ assess the quality and amplitude of vocal resonance. Types a. Bronchophony: Voice sounds appear to be heard near the earpiece of stethoscope and words are unclear, e.g. consolidation, cavity communicating with a bronchus, b. Aegophony: Voice sound has a nasal or bleating quality. On saying ‘E’, it will be heard as ‘A’ (E to A sign), e.g. consolidation, cavity. c. Whispering pectoriloquy: The patient is asked to whisper words at the end of expiration, and this whispered voice individual syllables are recognised clearly, e.g. pneumonic consolidation, cavity communicating with a bronchus
  • 66. Examination of RSName: Age: Sex: Address: Occupation: 1) General Physical Examination: Young patient moderately built and moderately nourished, well oriented to time place and person, conscious and cooperative Pallor Icterus Cyanosis Clubbing Edema Lymphadenopathy Temperature Pulse Respiratory Rate BP JVP
  • 67. 3) Examination of the Chest Inspection:  Trachea appears Central in Position  Shape of the chest is elliptical, Bilaterally symmetrical  Movement of the chest is equal on both sides and normal  Respiratory Movement  Rate : 14 – 18 Breaths per minute  Rhythm : Regular  Depth : Normal  Type : Abdominothoracic / Thoracoabdominal  Accessory muscles of Respiration not in use  No skeletal deformity seen  Apical impulse not seen/seen at Left 5th ICS medial to MCL  No dilated or engorged veins present  No scars or swelling or other visible pulsations seen
  • 68. Palpation:  Apical Impulse felt at Left 5th ICS medial to MCL and is of Normal Character  Trachea centrally Placed (slightly deviated to right side)  Expansion of the chest is normal and symmetrical, expansion is more at the base compared to apex and sides of chest  Measurement of the Chest Expansion  Transverse Diameter : ___cm  Anteroposterior Diameter : ___cm  Right/Left Hemithorax : ___cm  Chest circumference in expiration : ___cm  Chest circumference at full inspiration: ___cm  Chest expansion : ___cm  No tenderness present
  • 69. Area Right Left Supraclavicular area Equal on both sides Infraclavicular area Equal on both sides Mammary region Equal on both sides Inframammary region Equal on both sides Axillary region Equal on both sides Infra-axillary region Equal on both sides Suprascapular region Equal on both sides Interscapular region Equal on both sides Infrascapular region Equal on both sides  Vocal fremitus (VF)
  • 70. Percussion: Area Right Left Supraclavicular area Resonant Resonant Infraclavicular area Resonant Resonant Mammary region Resonant Dullness Inframammary region Dullness(5th ICS onwards) Dullness Axillary region Resonant Resonant Infra-axillary region Resonant Resonant Suprascapular region Resonant Resonant Interscapular region Resonant Resonant Infrascapular region Resonant Resonant
  • 71. Auscultation  Breath Sounds Area Right Left Supraclavicular area Vesicular Vesicular Infraclavicular area Vesicular Vesicular Mammary region Vesicular Vesicular Inframammary region Vesicular Vesicular Axillary region Vesicular Vesicular Infra-axillary region Vesicular Vesicular Suprascapular region Vesicular Vesicular Interscapular region Vesicular Vesicular Infrascapular region Vesicular Vesicular  No added Sounds
  • 72. Area Right Left Supraclavicular area Equal on both sides Infraclavicular area Equal on both sides Mammary region Equal on both sides Inframammary region Equal on both sides Axillary region Equal on both sides Infra-axillary region Equal on both sides Suprascapular region Equal on both sides Interscapular region Equal on both sides Infrascapular region Equal on both sides  Vocal Resonance (VR) Report: Examination of the respiratory system of the subject is clinically normal