Examination Of The Respiratory System

Examination of the respiratory system Ding Xuhong Department of Pulmonary Medicine Renmin Hospital, Wuhan University

Common symptoms Dyspnea Cough and sputum Hemoptysis Chest pain

Dyspnea Breathlessness inappropriate to the level of physical exertion, or even occurring at rest

• Severity Is the dyspnea related only to exertion? How far can the patient walk at normal pace on the level?

• Variability Are there good days or bad days? (seasonal variation) Are there any times of day or night that are usually worse than others?

Cough • Acute or chronic How long has the cough been present? • Time relationship Is the cough worse at any time of day or night?

• Precipitating factors Is the cough aggravated by anything, for example dust, pollen or cold air? • Productive or nonproductive Is sputum produced? • Type and quantity of sputum What does it look like? How much is produced?

Hemoptysis Coughing of blood in the sputum Is there any blood in the sputum? Is it fresh or altered blood? How often has it been seen and for how long? Difficulty in justify the origin of blood: gums, nose, stomach

Chest pain • caused by lung diseases usually arises from the pleura: pleuritic pain • caused by local invasion of the chest wall by a lung tumor: constant, unrelated to breathing

Pleuritic pain sharp, stabbing, made worse by deep breathing or coughing • inflammation of the pleura • spontaneous pneumothorax • pulmonary infarction

The Examination of The Respiratory System • Relevant anatomy • Examination of the chest • Putting it together

Relevant anatomy

Sternal angle (Louis angle) • The junction of the manubrium and body of the sternum • The location of other important structures at the same level: (1) the second rib; (2) the disc between the fourth and fifth thoracic vertebrae; (3) the bifurcation of the trachea; (4) the upper level of the atria of the heart

Major interlobar fissure (Oblique fissure) from 2nd thoracic spine downward and laterally, then anteriorly and medially to the sixth rib in the midclavicular line the upper border of the lower lobe

• Minor interlobar fissure (Horizontal fissure) a horizontal line from the sternum at the level of the fourth costal cartilage to meet the line of the major interlobar fissure the boundary between the upper and middle lobes

EXAMINATION OF THE CHEST Inspection of the chest Palpation of the chest Percussion of the chest Auscultation of the chest

Inspection of the chest Appearance of the chest Bilaterally symmetrical and elliptical in cross-section Kyphosis — forward bending Scoliosis — lateral bending Flattening — PA diameter < half of the transverse diameter Over-inflation (barrel-shaped chest) — PA diameter (in COPD)

Movement of the chest Symmetrical Intercostal recession (“Three

depressions sign”) A drawing in of the intercostal spaces with inspiration Severe upper airways obstruction, as in laryngeal disease, tumor of the trachea

Contradictory movement the lower ribs move inwards on inspiration instead of the normal outward movement (respiratory muscle fatigue)

Venous pressure right heart failure obstruction of the superior vena cava

Respiratory rate and rhythm 14-16 breaths/min Tachypnea Cheyne-Stokes breathing

Cheyne-Stokes respiration

Cyclic deepening and quickening of respiration, followed by shallowing and slowing of respiration, with a short period of apnea, then being repeated Severe cardiac failure, narcotic drug poisoning, neurological disorders occasionally seen in elderly persons

Sleep Apnea Central apnea complete cessation of respiratory effort during sleep

Obstructive apnea obstruction of the upper airways by soft tissues in the region of the pharynx, apnea despite continuation of respiratory effort

Palpation of the chest Chest expansion The examiner’s hands should be placed over the lower anterolateral aspect of the chest with the thumbs along the costal margin, each pointing toward the xiphoid process, and the palms and fingers extended over the anterolateral wall

• Expansion should be tested during both quiet and deep inspiration • Expansion may be limited in Acute pleurisy Fibrous thickening of the pleura Fractured ribs Other trauma to the chest wall Pneumothorax Atelectasis

Vocal fremitus The resonance of sounds in the chest made by the voice (the vibrations transmitted from the vocal cords to the chest as the patient repeats a phrase, ‘ninety-nine’) — detected with the hand on the chest

Percussion of the chest Method 1. The middle finger of one hand (usually

the left if the examiner is right-handed) is pressed firmly against the chest wall parallel to the ribs but with the palm and other fingers held off the skin

2. A very short quick blow is struck at the middle phalanx of the pleximeter finger with the tip of the middle finger of the right hand 3. When properly performed, the forearm is virtually stationary the entire movement being executed from the wrist

Notices 1.the plexor finger should strike the pleximeter finger only instantaneously and must be immediately withdrawn 2.compare one side of the thorax with the opposite side as you proceeds with the percussion 3.be sensitive to the vibratory sensations that are being received from the chest wall by the pleximeter finger

Percussion note Resonance Dullness (reduction of resonance)

short, high pitched, not loud, the pleximeter finger perceives relatively little vibratory sensation 1. Consolidation: the underlying lung more solid than usual 2. Pleural effusion: the pleural cavity contains fluid 3. Pleural thickening

Hyperresonance (increase in resonance) Pneumothorax: the pleural cavity contains air

Auscultation of the chest The breath sounds Normal breath sounds: vesicular Reduced: emphysema, pleural thickening or pleural effusion Bronchial breathing: louder, harsh, the expiratory sound has a more sibilant character than inspiratory sound consolidation of the lung (pneumonia)

Added sounds Stridor The noise is often both inspiratory and expiratory Associated with laryngeal disease or localized narrowing of the trachea or the large airways Wheezes musical sounds associated with airway narrowing

Widespread polyphonic wheezes dynamic compression of the bronchi accentuated in expiration when airway narrowing is present diffuse airflow obstruction, as in asthma and COPD Fixed monophonic wheezes localized narrowing of a single bronchus by a tumour or foreign body may be inspiratory or expiratory or both

Crackles Short, explosive sounds, produced by sudden changes in gas pressure related to the sudden opening of previously closed small airways COPD: crackles at the beginning of inspiration Bronchiectasis: localized loud and coarse crackles Diffuse interstitial fibrosis: fine and late inspiratory crackles

The pleural rub creaking or rubbing in character Pleural inflammation associated with pleuritic pain

Vocal resonance The resonance of sounds in the chest made by the voice (the vibrations transmitted from the vocal cords to the chest as the patient repeats a phrase, ‘ninetynine’)— detected through stethoscope

Not distinct syllables but a resonant sound Detecting the conductivity of the lungs Compare the area on one side with the corresponding on the other side

Consolidation: vocal resonance louder and clearer

Whispering pectoriloquy: much louder and clearer, in large area of consolidation

Egophony: nasal or bleating, ‘eee aaa’, over the area of large amount of pleural effusion

Putting it together The referred procedure for the examination of the chest

Observe the patient generally Ask the patient’s permission for the examination, and ensure lying back comfortably at 45 degrees Examine the hands Check the face tor anemia or cyanosis Observe the respiratory rate Inspect the chest movements and the anterior chest wall

Feel the position of the trachea, and check for lymphadenopathy Feel the position of the apex beat Check the symmetry of the chest movements by palpation Percuss the anterior chest and axillae Listen to the breath sounds Check the vocal resonance Check the tactile vocal fremitus

Sit the patient forward; Inspect the posterior chest wall Percuss the back of the chest Listen to the breath sounds Check the vocal resonance Check the tactile vocal fremitus Thank the patient and ensure the patient is dressed or appropriately covered

Interpreting the signs If movements are diminished on one side, there is likely to be an abnormality on that side The percussion note is dull over a pleural effusion and an area of consolidation

The breath sounds, the vocal resonance and tactile vocal fremitus are quieter or less obvious over a pleural effusion, and louder or more obvious over an area of consolidation

Over a pneumothorax, the percussion note is more resonant than normal but the breath sounds, vocal resonance and tactile vocal fremitus are quieter or reduced. Pneumothorax is easily missed