Clinical examination of respiratory system

The slides will be helpful to both UGs and PGs during clinical rounds.

1. CLINICAL EXAMINATION OF RESPIRATORY SYSTEM... Saswat..

2. THE SEQUENCE OF EXAMINATION...

3. INSPECTION Is what you see. 2 nd most important method of examination (2 nd to ??). Sitting up/standing/lying down position. Stripped upto the waist. Adequate light.

4. What to look for? Symmetry. Shape of the chest. Movement of the chest . Position of the trachea. Position of apical impulse.

5. Involvement of accessory muscles. Any visible scars, sinuses, engorged veins or fistulous tracts.

6. Presence of bony deformity: kyphosis or scoliosis. If the chest is asymmetrical: Drooping of shoulder. Spino -scapular distance. Lower border of scapula. Medial border of scapula. Arm-chest distance. Level of nipple.

7. The normal chest... The normal shape of the chest is ?? Ellipsoidal. B/l symmetrical. AP:T = 5:7. Subcostal or epigastric angle of almost 90 degree (more acute in males).

8. Abnormal shapes of the chest... Pectus carinatum / pigeon chest: Forward protrusion of the sternum. Straightening of the ribs in the front Congenital, rickets, chronic nasopharyngeal obstruction. Alar chest: Undue prominence of vertebral borders of scapula. Increased obliquity of ribs.

9. Funnel chest/ pectus excavatum / cobbler’s chest: Exagerated hollow over lower end of sternum. Congenital, occupational, Marfan’s syndrome. Barrel chest: Increased A-P diameter, ribs more horizontal. Sternum arched with prominent angle of Louis. Circular cross section. Emphysema, kyphosis of spine, old age.

10. Rachitic rosary: Pigeon chest. Harrison’s sulcus : grooves or depression on either side of xiphisternum , corresponding to costal attachments of diaphragm. Rickety rosary: bead-like enlargement of costochondral jn . (esp. 4-6 th ribs). Vertical grooves on either sides of sternum. Scorbutic rosary: Sharp angulation of the ribs. Backward displacement of sternum .

11. Barrel Chest… Pectus Carinatum

12. Pectus excavatum

13. Asymmetry of chest?

14. Quiz time!! Normal respiratory rate is? Which is active: Inspiration/expiration? Respiration to pulse ratio is?_____ Type of respiration in females? Thoracic/abdominal? What is the effect of opioid on respiration: pulse ratio?

15. Altered respiration to pulse ratio Heart block. Pneumonia. Opioid poisoning.

16. Palpation… Standing/ sitting position. For apical and upper zones, put 2 hands over the apical region with thumbs approximated in the midline. For middle and lower lobes, hands are placed on either side of the chest wall and thumbs are stretched to meet in the midline.

17. All inspection findings are confirmed. Position of trachea. Apex beat. Chest expansion. Measurements of hemithorax. Vocal fremitus. Same hand applied on both sides. Compare symmetrical areas. Increased in consolidation or fibrosis. Decreased in c/o fluid or air in pleural space. Maintain pitch and tone of voice .

18. Rib crowding. Localised swelling/tenderness.

19. Percussion…

20. Rules of percussion. Sitting/ standing/ recumbent. Pleximeter (middle finger of left hand) should be firmly placed on the chest wall along an interspace , with no interposed airpockets . Other fingers must be held away from the chest wall . The plessor (middle finger of the right hand) should hit the middle phalanx at 90 degree, with the pad of the finger. Movement of the plessor should be at the wrist .

21. The force of stroke varies on the thickness of the chest wall, age , sex and area of chest wall percussed. Proceed from resonant to dull areas or more resonant to less resonant areas. While delineating the borders, the long axis of pleximeter should be parallel to the expected border. The area must be equidistant from both ears.

22. Sequence of events… Direct percussion over clavicle (at medial 1/3 rd and lateral 2/3 rd ). Kronig’s isthmus. Resonant note. Abnormal percussion notes. Cardiac dullness. Liver dullness (at mid-clavicular line, mid-axillary line and scapular line). Traube’s space.

23. Shifting dullness. Succusion splash.

24. Types of percussion note. Resonant note: - low pitch. Lesions >5cm deep or <2-3cm do not alter the resonant note. Tympany: - normally on abdomen, trachea, larynx. drum-like. Superficial cavity. Subtympany / Skodaic resonance: - hyper-resonance with a boxy quality. Just above the level of pleural effusion/ consolidation.

25. Hyper-resonant note: - intermediate in pitch between resonance and tympany. u/l or b/l emphysema Pneumothorax, large bulla, compensatory emphysema Impaired note: - when part of a lung becomes comparatively airless. consolidation, collapse, fibrosis. Dull note: - consolidation, collapse, fibrosis. Stony dullness: - dullness associated with pain in the pleximeter finger of the examiner (like percussing on a rock). - Pleural effusion, mass lesion.

26. Cracked-pot resonance: - normally elicited over the chest of a crying infant. Lung cavity in communication with a bronchus due to sudden expulsion of air from cavity into the bronchus.

27. Kronig’s isthmus: - area of resonance connecting the large areas of resonance over the anterior and posterior aspects of each side of the chest. 5-7cm in width. Bounded medially by neck muscles, laterally by acromioclavicular joint, anteriorly by clavicle and posteriorly by trapezius. Percussed medially from the acromioclavicular joints.

28. Tidal Percussion…

29. Traube’s space: - area of tympanic note at the lower border of left lung. Bounded above by pulmonary resonance, below by the costal margin, liver on the right and spleen on the left. Content: fundus of the stomach. Ewart’s sign: area of dullness and a tubular breath sound at the angle of scapula in c/o a large pericardial effusion.

30. Shifting dullness: In c/o hydro- pnx or pyo-pnx or moderate PLEF. Delineate the upper border of dullness. With the pleximeter at that position, ask patient to lie down/bend forward Demonstrate resonance at the area of dullness.

31. Auscultation. Sitting/ standing position. Deep breathing with the mouth. Scheme of examination: Vesicular breath sounds. Abnormal breath sounds. Vocal resonance. Added sounds.

32. Normal breath sounds are produced at? Sound production is due to turbulent airflow. The higher pitched sounds are filtered as it is transmitted through the lungs.

33. Properties of the various breath sounds. Vesicular: - rustling or breezy quality (low pitched). Louder and longer inspiration. I:E=3-5:1. No pause. Characteristic in axillary and infrascapular regions. Tracheal sounds: - similar to bronchial breath sounds but louder. Bronchovesicular breath sounds: - intermediate quality between tracheal and vesicular. Normally heard at upper part of sternum, at level of T3-T4 posteriorly.

34. Abnormal breath sounds. Loud vesicular breath sounds: thin chest wall, compensatory emphysema. Reduced breath sounds: - Pain: pleurisy, percarditis , painful spine. Weakness of respiratory muscles: poliomyelitis. Decreased lung elasticity: emphysema. Decreased conduction of breath sounds: PLEF, pneumothorax, pleural thickening. Absent breath sounds: pneumothorax, PLEF, collapse.

35. Bagpipe sign: - In case of partial obstruction of a large bronchus, breath sound may be heard even after a forced expiration. This occurs due to delay in equalisation of both pressures. B/l in case of asthma and u/l implies partial obstruction of a large bronchus. Similar findings may be observed in inspiration where, if u/l signifies a large airway obstruction and b/l implies epiglottic/tracheal obstruction.

36. Bronchial breath sounds.. High-pitched. I:E =1:1. Pause between inspiration and expiration.

37. Tubular: - high pitched. Consolidation, massive PLEF (heard over lower part of back, as the collapsed LL conducts sounds from a large bronchus). Cavernous: - lower pitched. - Hollow character. Normal over occipital region. Cavity with irregular borders, open pneumothorax, pulled trachea.

38. Amphoric : - high pitched. echo-like/ metallic quality. Imitated by blowing across a bottle mouth/ open end of a rifle. Large cavity with smooth walls, pneumothorax communicating with a bronchus.

39. Representation of the various breath sounds.

40. Added sounds. Wheeze: - continuous musical sounds produced by flow through narrowed airways. Produced when air is forced past a point at which opposing walls are just touching.

41. Fixed monophonic wheeze: - constant pitch , timing and site. Produced when air passes at high velocity through a localised narrowing in a large airway. Intrabronchial mass lesion, fb, lymph node obstructing a bronchus .

42. b. Random monophonic wheeze: random single notes of varying duration, timing and pitch. E.g. bronchial asthma, bronchitis. c. Polyphonic: - expiratory musical soundcontaining several notes of different pitch. Due to oscillation of several large bronchi simultaneously brought to a point of closure by congestion of mucus lining, thickening of mucus and contraction of smooth muscles. COPD, asthma. [Inspiratory wheezes are called squawks].

43. 2. Crepitations: - interrupted, short, sharp non-musical sounds. Produced by snapping open of the airways causing sudden equalisation of pressures when a closed airway separating 2 adjacent compartments of the lung, that contain gas under widely different pressures. Early inspiratory: COPD (arises from large airways, coarser and not related to posture). Late inspiratory: ILD, pulmonary edema (arises from small airways, best heard at lung bases). Expiratory: severe airway obstruction. Clears on cough No change on bending forward.

44. [Crepitations in bronchiectasis is biphasic, coarse, leathery while that in ILD is fine, mid-to-late inspiratory].

45. 3 . Pleural rub: - due to rubbing of the 2 pleural surfaces. Commonest site is the lower part of axilla.

46. Other added sounds. Succussion splash: - splashing sound heard with a stethoscope when the chest of a patient is suddenly shaken. hydropneumothorax, herniation of abdominal contents into chest, large cavity filled with fluid. Hamman’s sign: - systolic crunching sounds heard over the left sternal border (3 rd -5 th intercostal space) with the patient in sitting position. Mediastinal emphysema , lt. pneumothorax, emphysema of lingula, lower esophageal dilation, dilation of stomach, pneumoperitoneum with ascent of lt diaphragm.

47. Interesting.. Post tussive suction: - medium or low pitched during long inspiration, following a bout of cough. Thin walled, collapsible lung cavity in communication with a bronchus. Falling drop sound: - metallic or tickling sound induced by change in posture, coughing or laughing. hydropneumothorax , large cavity with fluid and air. Due to fluid falling onto fluid level/ bursting of bubbles on water surface.

48. Water-whistle sound: - in case of a fistulous opening below the level of a fluid in case of a hydropneumothorax . Bubbling sound with a metallic quality.

49. Vocal resonance. Auscultatory equivalent of tactile VF. Heard as weak, muffled, indistinct sounds. Louder and clearer over trachea. Louder in suprasternal area, interscapular area, C7. Increased VR: consolidation, superficial cavity, compensatory emphysema. Decreased VR: PLEF, Pneumothorax , thickened pleura. Absent VR: pneumothorax , large PLEF .

50. Bronchophony : - spoken voice sounds are unduly loud and clear, although still indistinguishable. consolidation, above the level of PLEF. Aegophony : - spoken voice sounds have a peculiar nasal quality. Like the bleating of a goat. Above the level of PLEF, cavity filled with secretion.

51. Whispering pectoriloquy : - whispered voice sounds are transmitted to the chest wall with clearly distinguishable syllables. Cavity communicating with a bronchus, consolidation, above the level of PLEF.

52. D’espine sign… A whispering sound followed the spoken voice in some patients over the upper thoracic vertebra of some patients, which was not normal. He considered it to be the earliest sign of enlarged trachea-bronchial LN.