RESPIRATORY EXAMINATION FINAL PPT DR,.pptx

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1. Clinical Examination of the Respiratory System PRESENTED BY DR. RAM JIBAN YADAV FCPS MEDICINE RESIDENT CIVIL SERVICE HOSPITAL MINBHAWAN , KATHAMANDU , NEPAL

2. Anterior imaginary lines and landmarks E pigastric angle Infraclavicular fossa Anterior midline Suprasternal fossa Supraclavicular fossa Sternal line Parasternal line Midclavicular line

3. Lateral imaginary lines Anterior axillary line AAL Midaxillary line MAL Posterior axillary line PAL

4. Posterior imaginary lines and landmarks Scapular line Posterior midline Infrascapular region Interscapular region Suprascapular region

5. Anterior view of lobes

6. Posterior view of lobes

7. Right lateral view of lobes

8. Left lateral view of lobes

9. Sternal angle and ICS Suprasternal Notch Sternal Angle

10. Lung fissure and Borders Oblique fissure (Major interlobar fissure) Horizontal fissure (Minor interlobar fissure) T 2

11. EXAMINATION OF THE RESPIRATORY SYSTEM General Examination (RS) Examination of the Chest Upper Respiratory Tract Lower Respiratory Tract

12. General Examination P allor I cterus C yanosis C lubbing E dema L ymphadenopathy T emperature P ulse R espiratory Rate BP JVP

13. P allor (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

14. C yanosis 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 . TOUNGE , LIPS Impaired pulmonary function a. Alveolar hypoventilation b. Ventilation—Perfusion mismatch c. Impaired oxygen diffusion.

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 . C lubbing Bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue.

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. L ymphadenopathy 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. B lood P ressure 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 J ugular V enous P ulse COPD/ cor pulmonale Bilateral non-pulsatile SVC obstruction Massive right sided pleural effusion

21. Examination of the Chest 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 fossae 3. Crowding of ribs 4. Kyphosis (forward bending of the spine) 5. Scoliosis (lateral bending of the spine).

27. Inspection for Chest wall abnormalities Flat chest : The antero-posterior to transverse diameter ratio is 1 : 2. Seen in pulmonary TB and fibrothorax

28. 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. 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. Spinal Deformity Kyphoscoliosis or scoliosis : producing a shift of the apex beat. It reduces the ventilatory capacity of the lung and increases the work of breathing. Lateral bending Forward bending

33. 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 = thoraco -abdominal men = abdomino -thoracic • The ratio of pulse rate to respiratory rate is 4 : 1.

34. Tachypnoea Bradypnoea Hyperpnoea increase in respiratory rate more than 20 per minute(Adult) decrease in the rate of respiration. increase in depth of respiration. 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 a. Alkalosis b. Hypothyroidism ( myxoedema ) c. Narcotic drug poisoning d. Raised intracranial tension. a. Acidosis b. Brainstem lesion c. Hysteria.

35. Abnormal Breathing Patterns Abnormal breathing patterns may be regular or irregular Regular abnormal breathing patterns 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.

36. Irregular abnormal breathing patterns a. Biots breathing : apnoea between several shallow or few deep inspirations. occurs in meningitis b . Ataxic breathing : irregular pattern where both deep and shallow breaths occur randomly . occurs in brainstem lesions c. Apneustic breathing : by pause at full inspiration, alternating with a pause in expiration, lasting for 2 to 3 seconds. occurs in pontine lesions

37. Breathing Patterns

38. 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

39. 2. PALPATION I.POSITION OF APEX BEAT Cardiac impulse refers to movements occurring due to the impact of the heart against the chest wall during the systole. The apex beat is the lowest and outermost point of definite cardiac impulse, where it is seen / felt most forcibly (point of maximum impulse).

40. 2. PALPATION I POSITION OF APEX BEAT Normal position - 9 cm from midline in the left 5 th intercostal space .

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

42. 2. PALPATION

43. 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 II. Palpation for Position of trachea

44. III. 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

45. 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.

46. For Circumference expansion how to measure

47. Assessing Symmetry of Chest Expansion anterior thoracic expansion upper thoracic expansion posterior thoracic expantion

48. 2. PALPATION IV. TECTILE VOCAL FREMITUS (TVF ) The vibration may be detected by palpation by ulnar border of hand placed flat on the chest. The subject is then asked to repeat 1 1 1 or 9 9 9 or Ram Ram Ram Compare right and left side

49. Tactile Vocal fremitus (TVF)

50. TVF in front

51. IV. VOCAL FREMITUS

52. V. 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).

53. 3. PERCUSSION Normal percussion note of the lungs is resonant AREAS ON THE CHEST WALL Anteriorly: Supraclavicular, Clavicular, Infraclavicular , Mammary and Inframammary. Laterally : Axillary and Infra-axillary . Posteriorly : Suprascapular, Scapular, Infrascapular and Interscapular .

54. LUNGS PERCUSSION SITES:

55. Cardinal Rules of Percussion 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 The plexor : The middle or the index finger of the examiner’s right hand is used to hit the middle phalanx of the pleximeter The percussion movement should be sudden, originating from the wrist . The finger should be removed immediately after striking to avoid damping

56. Cardinal Rules of Percussion 4. Proceed from the area of normal resonance to the area of impaired or dull note, as the difference is then easily appreciated 5. Whenever delineating the border of an organ, such as the heart or the liver, the long axis of the pleximeter finger must be kept parallel to the expected position of that border. The area percussed must be more or less equidistant from the two ears of the examiner, in order to prevent wrong interpretation of sounds; the examiner must therefore directly face the centre of the patient chest , whenever possible.

57. 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 5 th rib downwards in the midclavicular line.

58. Lateral Chest Wall Fourth to seventh intercostal spaces. Liver dullness can be percussed from the right 8 th 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 10 th rib downwards in the midscapular line.

59. Summary :- 6 , 8 , 10 , 12 ‘’

60. Unchanged sound (resonance) The depth of the lesion > 5 cm The diameter of the lesion  3 cm Mild hydrothorax

61. TOPOGRAPHIC PERCUSSION OF LUNGS : Apical percussion – Diminution or absence of the supraclavicular zone of resonance – pulmonary tuberculosis. Increased extent of resonance, bilaterally – emphysema. Alternate method is mapping Kronig’s isthmus . Basal percussion – Lower border of lung resonance is depressed - emphysema or pneumothorax , and raised – lung fibrosis, collapsed lung, consolidation, ascites, massive abdominal tumour or pleural effusion .

62. 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 LIKE PULMONARY FIBROSIS, pleural effusion. 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.

63. 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.

64. 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. Identify any 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 sounds directly from the trachea or main bronchi.

65. produced by passage of air through the trachea and large bronchi low pitched, rustling in nature

66. Types of Bronchial Breathing a. Tubular :- HIGH PITCH , Consolidations , collapse with patent bronchus b. Cavernous :- low pitched : tuberculous cavity , lung abcess c. Amphoric . Low pitched :- brochopleural fistula

67. Added sounds 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 . B. Stridor It is a loud inspiratory sound heard over the airways due to obstruction to the respiratory tract mainly the larynx and trachea .

68. NEW Terms OLD Terms Definations coarse crackles PNEUMONIA PULMONARY EDEMA râles non- musical,interruptedshort , explosive sounds often described as bubbling or clicking or crackling sounds produced by sudden change in pressure related to sudden opening of previously closed airways. heard both during expiration and inspiration. fine crackles PULMONARY FIBROSIS crepitations wheezes rhonchi Continuous musical sounds associated with airway narrowing particularly heard during expiration Seen in bronchitis and bronchial asthma,COPD SOURCE :- OSCE GUIDE LATEST , UKMLA

69. Vocal resonance i s the detection of vibrations transmitted to the chest from the vocal cords as the patient repeats a phrase like ‘ ninetynine ’ assess the quality and amplitude of vocal resonance . 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.

70. Types A. Bronchophony :- T o say “ ninety- nine.” Normally == muffled and indistinct but if Louder, clearer voice sounds B . Aegophony : Voice sound has a nasal or bleating quality. Ask the patient to say “ ee .” You will normally hear a muffled long E sound. When “ ee ” is heard as “ay,” an E- to- A change ( egophony ) c . Whispering pectoriloquy : whisper “ninety- nine” or “one-two- three.” >>>normally heard faintly and indistinctly, if >> Louder , clearer whispered sounds at end of expiration

71. 4. AUSCULTATION