Clinical examination of Respiratory System by Pandian M, tutor, Dept of Physiology, DYPMCKOP,MH.

Materials
Symptoms
Examination of Resp. Sys:-
Inspection
Palpation
Percussion &
Auscultation
Examination of chest

1. Clinical Examination of the Respiratory System Pandian M Dept of Physiology DYPMCKOP

2. SLO Materials Symptoms Examination of Resp. Sys:- Inspection Palpation Percussion & Auscultation Examination of chest

3. Materials : Stethoscope, measuring tape and 2 cardboards Symptoms :- Pain in chest, fever, cough – dry or expectoration, blood in sputum ( haemoptysis ), breathlessness ( dyspnoea ), bluish discoloration of nails (cyanosis) . Examination of Resp. Sys:- It’s starts right from examination of Nose, Oral cavity and Throat

4. Examination Inspection Palpation Percussion & Auscultation

5. Examination of chest Position of subject:- sitting position. Inspection: Shape of the chest Movements of the chest sitting Position Size and shape – normal is bilaterally symmetrical, elliptical in cross section, transverse diameter greater than A-P dia., subcostal angle is 90 ̊ ( more acute in males ) Significance : size and shape get altered in different diseased condition, e.g.

6. Rickets

7. emphysema

8. Lateral bending Forward bending

9. Movements of chest Observation from foot end of bed tangentially or sitting position and note following points:- Rate & Rhythm during quiet resp . 12 – 18 breaths/ min, regular.(mostly observing abdominal wall) In children Resp.Rate is higher Causes of fast & shallow breathing ( Tachypnoea ) are : exercise,fever , nervousness, hypoxia. Causes of slow breathing are: brain damage. Expansion of chest – whether expansile & symmetrical (use tape ) { diminished or asymmetrical seen in - pneumothorax , collapse,consolidation , emphysema, pleural effusion } Types of breathing Abdomino thoracic Thoracico – abdominal Accessory muscles of resp – working or not

10. Position of trachea (Trial’s sign)

11. Position of apex beat Position of apex beat get displaced in diseases of lungs or pleura

12. Palpation Confirm the finding of inspection Size and shape Symmetrical (or) asymmetrical A-P diameter (measure by two cardboard) Transverse diameter (measure by two cardboard) Circumference is – at the end of Inspiration (normal ) at the end of Expiration (normal )

13. For Circumference expansion how to measure

14. Movements / Expansion of chest Sitting position :- for front and back

15. For Apical expansion

16. Position of Trachea

17. Position of Trachea

18. The trachea may be pushed away from the affected side by : pleural effusion or pneumothorax . The trachea may be pulled towards the affected side by fibrosis or collapse of the lung.

19. Position of apex beat

20. Apex beat may be displaced due to : scoliosis, enlargement of LV. Displacement of the mediastinum by disease of lungs or pleura.

21. Tactile Vocal Fremitus (TVF ) The detection, by palpation of tactile perception of vibration that are communicate to the chest wall – from the larynx via bronchi and lungs during the act of phonation is referred to as TVF. For TVF the subject repeat the word like ninety nine or one bcoz of nasal twang, then the examining hand perceives distinct vibrations. Determine whether the vibration in corresponding areas on two identical sides of chest approximately equal intensity or not

22. Tactile Vocal fremitus (TVF)

23. TVF in front

24. TVF is ↑ sed when the lung is consolidated or contains large cavity near surface. TVF is ↓ sed when the corresponding bronchi are obstructed . TVF is totally absent when the lung is separated from chest wall by pleural effusion or pneumothorax

25. Percussion

26. Place the palm of your left hand on the chest, with your fingers slightly separated . Press the middle finger of your left hand firmly against the chest, aligned with the underlying ribs over the area to be percussed . Strike the centre of the middle phalanx of your left middle finger with the tip of your right middle finger, using a loose swinging movement of the wrist and not the forearm. Remove the percussing finger quickly so the note generated is not dampened. Percuss the lung apices by placing the palmar surface of your left middle finger across the anterior border of the trapezius muscle, overlapping the supraclavicular fossa and percussing downwards. Percuss the clavicle directly over the medial third, as percussing laterally is dull over the shoulder muscles.

27. To percuss the upper posterior chest ask patients to fold their arms across the front of their chest, thereby moving the scapulae laterally. Do not percuss near the midline, as this produces a dull note from the solid structures of the thoracic spine and paravertebral musculature. Map out abnormal areas by percussing from resonant to dull.

28. AREAS ON THE CHEST WALL for PERCUSSION

29. AREAS ON THE CHEST WALL Anteriorly : Supraclavicular , Clavicular , Infraclavicular , Mammary and Inframammary . Laterally : Axillary and Infra- axillary . Posteriorly : Suprascapular, Scapular, Infrascapular and Interscapular.

30. Lower border of Right lung:- In the anterior aspect, the lower right border of the lung extends upto the 6 th rib in the mid clavicular line 8 th rib in the mid axillary line and 10 th rib in the mid scapular line Lower border of Left lung:- Anterior aspects its overlaps by stomach 8 th rib in the mid axillary line overlaps by spleen 10 th rib in the mid scapular line

31. Increase in resonance ( or hyperresonance ) – pneumothorax & lung collapsed towards the hilum . Reduction in resonance (dullness to percussion) – pleura is thickened, pleural caviy contains fluid (stony dullness)

32. Types of breath sounds: air entry, present or not, equal or not Vesicular breath sounds Bronchial breath sounds: Vesicular breath sounds – Produced by movement of air in and out of normal lung tissue. Sounds are rustling of leaves Heard all over the chest wall. Duration and intensity of inspiration are more than that in expiration. There is no gap/pause between inspiration and expiration. Most typically heard in the axillary and infrascapular region. Low pitched with frequencies between 200 – 600 Hz.

33. Bronchial breath sounds: The sound originates in larger airway and is transmitted directly to the chest wall without passing through the lung tissue. This is heard sometimes in interscapular region T1 to T4 and resembles the sound over the trachea. Sounds are hollow, tubular, blowing in nature. Duration and intensity of expiration is more than inspiration. There is a gap/ pause between inspiration and expiration. They are high pitched with frequencies above 600 Hz. Heard in pathological conditions like cavity and consolidation.

34. Auscultation

35. Added sounds Rhonchi / Wheeze :- prolonged uninterrupted musical sounds, particularly heard during exp (bronchial asthma and bronchitis) Crepitations / crackles:- short, explosive sounds often described as bubbling or clicking noises. (pneumonia, TB, bronchitis) , they may be fine or coarse. Pleural rub:- pleural inflammation, creaking/rubbing character

36. Vocal resonance Sounds heard over various parts of the chest during the act of speech Vocal resonance is auscultatory equivalent of TVF. The same laws govern the mode production, transmission, elicitation and abnormalities as seen in TVF. Each point examined on one side of the chest should be at once compared with corresponding point on other side.

37. VR ↑ sed VR markedly ↑ sed Bronchophony Further ↑ sed in VR called Whispering pectoriloquy Consolidation VR is either abolished or much diminished in cases of – pleural effusion, pneumothorax , emphysema.

38. References Text book of Medical Physiology Guyton & Hall Hutchinson Clinical Methods Practical Physiology Manual A.K. Jain, C.L. Ghai , G.K. Pal Net source for pictures

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