Systemic examination of respiratory system

detailed systemic examination of respiratory system-inspection,palpation,percussion and auscultation

1. INSPECTION Shape of the chest Normal : Bilaterally symmetrical and elliptical in cross section AP:Trans =5:7 Chest deformity Flat chest: AP:Trans =1:2 Pulmonary TB F ibrothorax

2. Contd.. Barrel shaped chest: AP:Trans =1:1 Physiological: Infancy,old age Pathological: COPD Pigeon chest(Pectus carinatus ): Forward protrusion of sternum and adjacent costal cartilages Rickets Childhood asthma Marfan’s syndrome

3. Contd.. Funnel chest(Pectus excavatum): Exaggeration of the normal hollowness on the lower end of sternum Development defect: Apex beat is shifted further to the left and the vital capacity is restricted Marfan’s syndrome Scorbutic rosary: Sharpangulation with or without beading or rosary formation of the ribs D/t backward displacement of sternum Vit C deficiency

4. Contd.. Harrison’s sulcus : D/t indrawing of the ribs to form symmetrical horizontal groove above the costal margin,along the line of attachment of the diaphragm d/t hyperinflamation of the lung and reapeated strong contraction of the diaphragm Chronic respiratory Dzs in childhood Childhood asthma Rickets Rickety rosary : Bead like enlargement of costochondral junction Rickets

5. Movement of the chest: Movement of the chest with respiration Movement of the chest equally on both side a) Unilateral: b) Bilateral Pleural effusion Emphysema Chest trauma Hydrothorax Pneumothorax Obesity Hydropneumothorax Bronchial asthma Consolidation Diffuse interstitial fibrosis Fibrosis of lung Myasthenia gravis

6. Contd.. Apical Impulse: Stand on the right side of the patient and look tangentially over the precordium Helps to note the precordial shift Tracheal deviation: Ask the patient to look forward an look for any deviation

7. Contd.. Respiration: Rate Rhythm Type Venous Prominance : Superior venacava syndrome: Presence of distended vein over the chest wall

8. Contd.. Retraction/Fullness of intercostal space: Abnormal retraction: Severe asthma COPD Upper airway obstruction Fullness of intercostal space: Pleural effusion Haemothorax pneumothorax

9. Contd.. Level of nipple: Whether both the nipple are at the same level or not Skin over the chest: C old abscess Ulcer Swelling Scar mark

10. Contd.. Accessory muscle: Whether accesory muscles of respiration are working or not Inspiration:Active process d/t contraction of the intercostal muscles and diaphragm Muscles: Scalene Sternocleidomastoid Platysma Pectoralis Serratus anterior Expiration: Passive process d/t elastic recoil of the lung Muscles Abdominal recti muscles latissimus dorsi

11. palpation Surface temperature Tenderness: Rib tenderness: T rauma, fracture Intercostal tenderness: Liver abscess, empyema thoracis Corroboration of inspetory findings Spinal deformity

12. Contd.. Position of trachea and apex beat Palpate in the standing or sitting position with arm placed symmetrically on two sides. Flex the neck with left hand so that chin remain in same side Insert the tip of index finger in suprasternal notch Feel the tracheal ring Now side the index finger in the angle between sternocleidomastoid muscles and trachea on both side On the deviated side angle is narrowed and feel resistant

13. Contd.. Shift of trachea: To the same side To the opposite side Fibrosis of lung Massive pleural effusion Collapse of lung Pneumothorax pneumonectomy Hydropneumothorax

14. Contd.. Movement of chest: Upper part of thorax: Face the patient’s back Place both hands over the patient’s supraclavicular fossa. Compare on both sides the extent of upward movement of the hands during quiet respiration

15. Contd.. Anterior thoracic movement: Face the patient Keep the finger tip of both the hands on either side of patients rib cage so that the tip of thumbs approximate each other in midline without touching the chest wall Ask the patient to take deep breath Compare the movement of thumbs on both sides away from midline It can also be assessed by holding a loose fold of skin between the thumbs and noting their separation

16. Contd.. Posterior thoracic movement Perform at the infrascapular region

17. Contd.. Chest expansion: Done using inch tape In male: measure at the level of nipple In female: measure just below breast Measure normal circumference of chest Ask to take deep inspiration, again measure the chest circumference Difference between the two is known as chest expansion Normal expansion=5-8cm

18. Contd.. Decreased chest expansion Unilateral Bilateral Pleural effusion Emphysema Pneumothorax Hydrothorax Collapse of lung Bronchial asthama Fibrosis of lung Myasthenia gravis

19. Contd.. Vocal fremitus : palpation of laryngeal vibration on the chest wall when patient is asked to repeat 9-9 or 1-1-1 Place the flat of hand or ulnar border of the right hand over the intercostal space Compare the patient to tell 9-9 or 1-1-1 Compare on both side Increased: Consolidation Decreased: Pleural effusion

20. Percussion Cardinal rules: Method: Place the middle finger of the left hand( pleximeter ) of the examiner firmly over the chest wall over the ICS such that other finger don’t touch the chest wall Then strike the centre of middle phalanx of the pleximeter finger with the tip of middle finger of right hand( plexor ) The finger should be moved immediately after the striking action in tapping movement. The percussion finger is bent to make its terminal phalanx right angled so that it strikes the other finger perpendicularly

21. Contd.. The percussion movement should be sudden originating from the wrist Always percuss the opposite side of chest on the equivalent position and compare with notes on other side

22. Contd.. Position of the patient: Sitting position is the best for percussion Supine position is not desirable because of the alteration of percussion note by the underlying structure in which patient lies

23. Contd.. For anterior percussion: Patients should sit erect with hands by his side For posterior percussion : patient should bend his head forward and keep his hands over the shoulder.This position keep the two scapula away so that more lung field is available for percussion Lateral percussion: The patient should sit with his hand held over the head

24. Area of percussion Anterior chest wall: Clavicle: Direct percussion Percussion is done within middle 1/3 rd of clavicle Supraclavicular region It is a band of resonance 5-7cm size over the supraclavicular fossa

25. Boundaries: Medially: Scalenus muscle of neck Laterally: Acromian process of scapula Anteriorly: Clavicle Posteriorly: Trapezius The percussion is done by standing behind the patient and resonance of the lung apices is assessed Hyper resonance: Emphysema Impaired resonance: Pulmonary TB

26. Infraclavicular : 2 nd to 6 th ICS; however the percussion note cannot be compared due to relative cardiac dullness on the left side

27. Contd.. Lateral chest wall Percuss from 4 th to 8 th ICS in mid axillary line

28. Contd.. Posterior chest wall Suprascapular Interscaular Infrascapular region upto the 11 th ICS Types of percussion note Lesion Tympanitic Hollow viscus 2. Sub tympanitic Above the level of pleural effusion 3. Hyper-resonant Pneumotharax 4. Resonant Normal lung 5. Impaired Pulmonary fibrosis 6. Dull Consolidation,collapse 7. Stony dull Pleural effusion,haemothorax

29. Auscultation Preliminaries Auscultation is carried out with diaphragm of stethoscope as most respiratory sound are high pitched Listen with the patient relaxed and breathing deeply through an open mouth. Instruct the patient to turn the face to one side, ask to breath regularly and deeply through open mouth

30. Contd.. Auscultate the both sides alternately Avoid auscultation within 3cm of the midline anteriorly and posteriorly as these area may transmit sounds directly from the trachea or main bronchi Listen anteriorly from above the clavicle down to the 6 th rib, laterally from axilla to the 8 th rib and posteriorly down to the level of the 11 th rib In each area listen to the quality and amplitude of breath sound

31. Contd.. Position of the patient: Sitting position Auscultatory area: Anterior: From an area above the clavicle down to 6 th rib Axilla: Area upto 8 th rib Posterior: Above the level of spine of scapula down to 11 th rib

32. Contd.. Breath sounds Breath sounds are produced by vibration of vocal cord due to turbulent air flow in larger airways which is conducted by the overlying lung tissue to the chest wall

33. Contd.. Vesicular breath sound: Vesicular breathing. Respiratory sounds known as   vesicular breathing arise due to vibration of the elastic elements of the alveolar walls during their filling with air in inspiration.  The alveoli are filled with  air in sequence. Therefore, the summation of the great  number of  sounds produced during vibration of the  alveolar walls gives a long soft (blowing) noise that can be  heard during the entire inspiration  phase, its intensity gradually increasing.

34. Contd.. Normal vesicular breathing is better heard over the anterior surface of the chest, below the 2nd rib, laterally of the parasternal line, and also in the axillary regions and below the scapular angle, i.e. at points where the largest masses of the pulmonary tissue are located. Vesicular breathing is heard worse at the apices of the lungs and their lowermost parts, where the masses of the pulmonary tissue are less abundand . While carrying out comparative auscultation, it should be remembered that the expiration sounds are louder and longer in the right lung due to a better conduction of the laryngeal sounds by the right main bronchus, which is shorter and wider.

35. Contd.. Condition with diminished vesicular breath sound: Bronchial asthma Tumor Pleural effusion Pleural thickeing Emphysema

36. Contd.. Bronchial breath sound: Respiratory sounds known as bronchial or tubular breathing  arise  in the  larynx  and  the  trachea as air passes through the vocal slit .   As air is inhaled, it passes through the vocal slit to enter wider trachea where it is set in vortex-type motion. Sound waves thus generated propagate along the air column throughout the entire bronchial tree. Sounds  generated by the vibration of these waves are harsh .

37. Contd.. During expiration, air also passes through the vocal slit to enter a wider space of the larynx where it is set in a vortex motion . But since the vocal slit is narrower during expiration, the respiratory sound becomes louder, harsher and longer. This type of breathing is called laryngotracheal (by the site of its generation).

38. Contd.. Bronchial breathing is well heard in physiological cases over the larynx, the trachea,  and  at  points of projection of the  tracheal bifurcation (anteriorly, over the manubrium sterni , at the point of its junction with the sternum, and posteriorly in the interscapular space, at the level of the  3 rd and 4th  thoracic vertebrae ). Bronchial breathing is not heard over the other parts of the chest because of large masses of the pulmonary tissue found between the bronchi and the chest wall.

39. Contd.. Types of bronchial breathing: Tubular: They are high pitched and present in: pneumonic consolidation collapse lung Cavernous: They are low pitched and heard in the presence of thick walled cavity with a communicating bronchus Amphoric : They are low pitched, with a high tone and metallic quality and present in: Bronchopleural fistula Tension pneumothorax

40. Contd.. Causes of absent breath sound: Pleural effusion(massive) Thickned pleura Pneumothorax Collapsed lung

41. Contd.. Added sounds Crackles: They are non musical, interrupted added sounds of short duration. They are explosive in nature Types: Fine: less loud,short,arise from alveoli Coarse: Low pitched,loud nd arise frombronchi and bronchioles

42. Contd.. Crackles may be: Early inspiratory: C hronic bronchitis Mid inspiratory: Bronchiectasis Late inspiratory: Asbestosis,pulmonary fibrosis,pneumonitis Expiratory: Chronic bronchitis Mechanism of crackles: B ubbling or flow of air through secretion in the bronchial level

43. Contd.. Ronchi They are musical,continuous added sounds. They may be: Low pitched: arising from large airways High pitched: arising from small airways Eg . Tumors Foreign body Bronchial asthma Emphysema

44. Contd.. Wheeze: Wheezing is a high-pitched whistling sound made while breathing . Most commonly wheezing occurs during breathing out (expiration), but it can sometimes be related to breathing in (inspiration ) Wheezing results from a narrowing of the airways and typically indicates some difficulty breathing. The narrowing of the airways can be caused by inflammation from asthma, an infection, an allergic reaction, or by a physical obstruction, such as a tumor or a foreign object that's been inhaled.

45. Contd.. The most common cause of recurrent wheezing is asthma. Possible causes of wheezing include: Allergies Anaphylaxis (a severe allergic reaction, such as to an insect bite or medication ) Asthma Bronchiectasis Bronchiolitis (especially in young children ) Pneumonia Respiratory syncytial virus (RSV)

46. Contd.. Causes(contd..) Bronchitis COPD(chronic obstructive pulmonary disease) and other lung diseases Emphysema Foreign object inhaled: First aid GERD(gastroesophageal reflux disease ) Heart failure Lung cancer

47. Contd.. Vocal resonance: It is a voice sound heard with the chest piece of stethoscope Increased vocal resonance: Consolidation Collapse with patent bronchus Open pneumothorax Decreased vocal resonance Pleural effusion Pneumothorax Emphysema

48. Contd.. Aegophony The voice may sound nasal or bleating; heard over the level of a pleural effusion,or in some cases over an area of consolidation Pleural rub It is superficial localized grating sound best heard with pressure of stethoscope It is produced when inflamed parietal and visceral pleura move over one another Not altered by coughing and usually associated with pleuritic pain