Physical Examination in Respiratory System Zhao Li, M.D

Physical Examination Physical Examination in Respiratory Systemin Respiratory System

Zhao Li, M.D.Zhao Li, M.D.

Anterior imaginary lines and Anterior imaginary lines and landmarkslandmarks

epigastric angle

Infraclavicular fossa

Anterior midline

Suprasternal fossa Supraclavicular fossa

Sternal line

Parasternal line

Midclavicular line

Lateral imaginary lines Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line

Posterior imaginary lines and Posterior imaginary lines and landmarkslandmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region

Anterior view of lobesAnterior view of lobes

Posterior view of lobesPosterior view of lobes

Right lateral view of lobesRight lateral view of lobes

Left lateral view of lobesLeft lateral view of lobes

Thoracic deformity Thoracic deformity

Pectus excavatumBarrel chest

Kyphosis

Inspection Inspection

1. Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult

2. Respiratory rate: 16-18 f/min Tachypnea: >20 f/min Bradypnea: <12 f/min Shallow and fast

respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy

Deep and fast Agitation, intension

Deep and slow Severe metabolic acidosis (Kussmaul’s breathing)

Inspection Inspection

3. Respiratory rhythm Cheyne-Stokes’ breathing Biot’s breathing

_____Decreased excitability of respiratory center Inhibited breathing

Sudden cessation of breathing due to chest pain

Pleurisy, thoracic trauma Sighing breathing

Depression, intension

Palpation Palpation

Thoracic expansion

Massive hydrothorax, pneumonia, pl

eural thickening, atelectasis

Vocal fremitus (tactil fremitus)

Pleural friction fremitus

Cellulose exudation in pleura due to

pleurisy

Holding breathing disappeared

Tuberculous pleurisy, uremia, pulmo

embolism

PercussionPercussion

1. Method1. Method

Mediate Pleximeter: distal inter-phalangeal joint of left middle fi

nger Plexor: right middle finger tip

Immediate Order

Up to down, anterior to posterior

2. Affected factors2. Affected factors

Thickness of thoracic wall Calcification of costal cartilage Hydrothorax Containing gas in alveoli Alveolar tension Alveolar elasticity

3. Classification3. Classification

Resonance Normal

Hyperresonance Emphysema

Tympany Cavity or pneumothorax

Dullness Hydrothorax, atelectasis

Flatness Massive Hydrothorax

4. Normal sound4. Normal sound

Lung’s sound in percussion Resonance Slight dullness in some areas (upper, right,

back) due to thickness of muscles and skeletons


Border of lungs in percussion Apex of lungs

Kronig’s isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema

Anterior border absolute cardiac dullness area

Lower border 6th, 8th, 10th intercostal space in midclavicular line, midaxillary l

ine, scapular line, respectively Down: emphysema Up: atelectasis, intraabdominal pressure goes up


s

Shifting range of bottom of lung

6-8 cm

Shifting range of bottom of lung

Along the scapular line

Percussing bottom of lung, marking

Asking the pat. to inspire deeply and hold


Asking the pat. to expire deeply and hold


Measuring the dist. between upper and lower lines

Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia

Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphra

gmatic paralysis

5. Abnormal sound5. Abnormal sound

Dullness, flatness, hyperresonance or tympany appear in the area of supposed resonance.

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


Dullness or flatness Decreased containing gas in alveoli

Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis

No gas in alveoli Tumor Pulmo. Hydatid (肺包虫 ) Pneumocystis (肺囊虫 ) Non-liquefied lung abscess

Others Hydrothorax Pleural thickness

5. Abnormal sound5. Abnormal sound Hyperresonance

Emphysema Tympany

Pneumothorax Large cavity (TB, lung abscess, lung cyst)

Amphorophony (空瓮音 ) Large and shallow cavity with smooth wall Tension pneumothorax

Tympanitic dullness (浊鼓音 ) Decreased tension and gas in alveoli

AtelectasisCongestive or resolution stage of pneumoniaPulmo. edema


Special areas on percussion in moderate

hydrothorax

Damoiseau’s curve

Garland’s triangle area

(tympanitic dullness)

Grocco’s triangle area

(dullness)

AuscultationAuscultation

Order of auscultation Order of auscultation

Sound of auscultationSound of auscultation

1. Normal breath sound

2. Abnormal breath sound

3. Adventitious sound

4. Vocal resonance (语音共振 )

1. Normal breath sound1. Normal breath sound

Tracheal breath sound Bronchial breath sound

Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra

Bronchovesicular breath sound 1st, 2nd intercostal space besi

de of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung

Vesicular breath sound Most area of lungs

Bronchovesicular

Bronchial

Bronchial

Bronchovesicular

2. Abnormal breath sound2. Abnormal breath sound

Abnormal vesicular breath sound

Abnormal bronchial breath sound

Abnormal bronchovesicular breath sound

Abnormal vesicular breath Abnormal vesicular breath soundsound(1)(1)

1) Decreased or disappeared Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor

2) Increased Movement of respiration

Abnormal vesicular breath sound Abnormal vesicular breath sound (2)(2)

3) Prolonged expiration Bronchitis Asthma emphysema

4) Cogwheel breath sound TB Pneumonia

5) Coarse breath sound Early stage of bronchitis or pneumonia

Abnormal bronchial breath soundAbnormal bronchial breath sound (tubular breath sound)(tubular breath sound)

Bronchial breath sound appears in supposed vesicular breath sound area

Consolidation: lobar pneumonia (consolidation stage)

Large cavity: TB, lung abscess

Compressed atelectasis: hydrothorax, pneumothorax

Abnormal bronchovesicular breatAbnormal bronchovesicular breath soundh sound

Bronchovesicular breath sound appears in supposed vesicular breath sound area

The lesion is relatively smaller or mixed with normal lung tissue

3. Adventitious sound3. Adventitious sound

(moist) Crackles

Rhonchi (wheezes)

Pleural friction rub

Moist crackles Moist crackles

Mechanism

During inspiration, air flow passes thin secretion

in the airway to rupture the bubbles, or to open t

he collapse of bronchioli due to adhesion by sec

retion.

Characteristics of cracklesCharacteristics of crackles


2. Intermittent

3. Appeared in phase of inspiration or early expiration

4. Constant in site

5. Unchanged in character

6. Medium and fine crackles exist meantime

7. Less or disappeared after cough

Classification of cracklesClassification of crackles

According to intensity of the sound1. Loud moist crackles2. Slight moist crackles

According to diameter of the airway crackles appeared1. Coarse: trachea, main bronchi, or cavity

Bronchiectasis, pulmo. edema, TB, lung abscess, coma2. Medium: bronchi

bronchitis, pneumonia3. Fine: bronchioli

pneumonia4. Crepitus:

Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time

Site of cracklesSite of crackles

1. Local: local lesion Pneumonia, TB, bronchiectasis

2. Both bases Pulmo. edema, bronchopneumonia,

chronic bronchitis

3. Full fields Acute pulmo. edema, severe bronchopneumonia,

chronic bronchitis with severe infection

Rhonchi (wheezes)Rhonchi (wheezes)

Mechanism The turbulent flow is formed in trachea, bronchi or bro

nchioli due to airway narrow or incomplete obstruction.Causes

Congestion Secretion Spasma Tumor Foreign subject Compression

Characteristics of rhonchi Characteristics of rhonchi


2. High pitch

3. Dominance in phase of expiration

4. Variable intensity of character or site

5. Wheezing

Classification of rhonchiClassification of rhonchi

1. Sibilant (高调 )

Bonchioli, bronchi

2. Sonorous (低调 )

Trachea, main bronchi

Site of rhonchi Site of rhonchi

1. Both fields Asthma Chronic bronchitis Acute left heart failure

2. Local site Tumor Endobronchial TB

Pleural friction rubPleural friction rub

1. Cellulose exudation in pleurisy (rough pleura)2. Area of auscultation

Anterolateral thoracic wall (maximal shifting area of lung)

3. Friction rub disappeared if holding breath4. Friction rub appeared both breath and heart beat: mediastinal pleurisy5. Causes

Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma

Vocal resonanceVocal resonance

Bronchophony (支气管语音） Consolidation

Pectoriloqny (胸语音 ) Massive consolidation

Egophony (羊语音 ) Upper area of hydrothorax

Whispered (耳语音 ) Consolidation

Main symptoms and signs in Main symptoms and signs in common respiratory diseasescommon respiratory diseases

Labor pneumoniaLabor pneumonia

Symptoms Symptoms

Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum

Signs (1)Signs (1)

General signs Acute facial features, blushing Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lips

Signs (2)Signs (2)

Congestion Inspection Decreased respiratory movement Palpation Increased vocal r

Chronic bronchitis with Chronic bronchitis with emphysemaemphysema

Symptoms Symptoms

Chronic productive cough White mucous sputum or pus sputum (infection) Exertional dyspnea Breathlessness (dyspnea) Chest depression

Signs Signs

Barrel chest Movement of respiratory Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)

Bronchial asthmaBronchial asthma

Symptom Symptom

Expiratory dyspnea with wheezing

Signs Signs

Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs

HydrothoraxHydrothorax(pleural effusion)(pleural effusion)

Symptoms Symptoms

Dry cough Chest pain

Disappeared with growing of pleural effusion Reappeared with the fluid decreasing

Affected side lying Dyspnea, orthopnea The symptoms of underlying disease

Signs Signs (Moderate to massive effusion)(Moderate to massive effusion)

Tachypnea Limited movement of affected side Costal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Pleural friction rub Abnormal bronchial breath sound in upper area of the flu

id

Pneumothorax Pneumothorax

Symptoms Symptoms

Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough

Tension pneumonia Progressive dyspnea Tyckycardia Cyanosis Respiratory failure

Signs Signs

Costal interspaces in affected side are wider Limited movement of affected side Decreased vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or disappear

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Physical Examination in Respiratory System Zhao Li, M.D