CLINICAL EXAMINATIONOF THE RESPIRATORY SYSTEM By, Dr.Prajwal

Different Lines

Vertebra prominence

Sternal angle and ICSSuprasternal Notch

Sternal Angle

1. 2nd Rib joins2. Arch of Aorta(beginning and

the end)3. Trachea bifurcates into the

two bronchi4. Pulmonary trunk bifurcation5. Left recurrent laryngeal

nerve looping under the arch of the aorta

6. Azygous Vein draining into the superior vena cava.

7. Thoracic duct emptying into the left subclavian vein

Lung fissure and Borders

Lung fissure and Borders

Oblique fissure (Major interlobar fissure)

Horizontal fissure (Minor interlobar fissure)

T2

EXAMINATION OF THE RESPIRATORY SYSTEM

1)General Examination (RS)2)Examination of the Chest

Upper Respiratory Tract Lower Respiratory Tract

1)General ExaminationPallorIcterusCyanosisClubbingEdemaLymphadenopathy

TemperaturePulse

Respiratory RateBPJVP

Pallor (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 isa. Haemoptysisb. Excessive sputum production and protein lossc. Loss of appetite leading to malnutrition

CyanosisThis 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.

Impaired pulmonary functiona. Alveolar hypoventilationb. Ventilation—Perfusion mismatchc. Impaired oxygen diffusion.

Bulbous enlargement of the distal portionof the digit due to increased subungual soft tissue.

Clubbing

Grading of Clubbing

Grade I Positive nail bed fluctuationGrade II Obliteration of the Lovibond angle Grade III Parrot beak / Drumstick appearanceGrade IV Hypertrophic osteoarthropathy.

Pulmonary and Thoracic Causesa. Bronchogenic carcinoma (rare in adenocarcinoma)b. Metastatic lung cancerc. Suppurative lung disease

1. Bronchiectasis2. Cystic fibrosis3. Lung abscess4. Empyema

d. Interstitial lung diseasee. Longstanding pulmonary tuberculosisf. Chronic bronchitisg. Mesotheliomah. Neurogenic diaphragmatic tumouri. Pulmonary AV malformationj. Sarcoidosis.

Hypertrophic Osteoarthropathy

It is a painful swelling of the wrist, elbow, knee, ankle,with radiographic evidence of sub-periosteal new boneformation. It can be familial or idiopathic.

common disorders that can produce it are:a. Bronchogenic carcinomab. Cystic fibrosisc. Neurofibromad. A-V malformation.

LymphadenopathyScalene lymph node enlargement1. Large and fixed in secondary involvement from aprimary lung malignancy2. Hard and craggy, matted, with or without sinusformation in healed and calcified tuberculouslymphadenopathy.

Blood PressurePulsus 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.

Examination of the Neck VeinsJugular Venous PulseCOPD/cor pulmonaleBilateral non-pulsatile

SVC obstructionMassive right sided pleural effusion

2) Examination of the Chest Inspection Palpation Percussion AuscultationThe subject should be examined in the Standing or Sitting position in an erect, and in good light.

All the findings in the clinical examination should be compared on both sides in the following areas:

1. Supraclavicular area2. Infraclavicular area3. Mammary region4. Inframammary region5. Axillary region6. Infra-axillary region7. Suprascapular region8. Interscapular region9. Infrascapular region.

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

Inspection for Position of tracheaTrail’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 BeatThe apex beat is shifted to the side of mediastinal shift.

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

Look for the following:1. Drooping of the shoulder2. Hollowness or fullness in the supraclavicular and infraclavicular fossae3. Crowding of ribs4. Kyphosis (forward bending of the spine)5. Scoliosis (lateral bending of the spine).

Inspection for Chest wall abnormalities1.Flat chest: The antero-posterior to transverse diameter ratio

is 1 : 2. Seen in pulmonary TB and fibrothorax

2.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)

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

4.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

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

6. Scorbutic rosary: It is the sharp angulation, with or without beading or rosary formation, of the ribs, arising as a result of backward displacement orpushing in of the sternum, e.g. Vitamin C deficiency.

7. Rickety rosary: It is a bead like enlargement of costochondral junction, e.g. rickets

Spinal DeformityKyphoscoliosis : It is a disfiguring or disabling deformity of the spine, producing a shift of the apex beat. It reduces the ventilatory capacity of the lung and increases the work of breathing.

Inspection for Movement of the ChestIt is described in terms of rate, rhythm, equality and type of breathingRate

• The normal respiratory rate in relaxed adults is 14-18breaths per minute• The type of breathing in women is thoraco-abdominaland in men is abdomino-thoracic• The ratio of pulse rate to respiratory rate is 4 : 1.

Tachypnoea: It is an increase in respiratory rate morethan 20 per minute(Adult). Conditions causing tachypnoeaare:a. Nervousnessb. Exertionc. Feverd. Hypoxiae. Respiratory conditions

i. Acute pulmonary oedemaii. Pneumoniaiii. Pulmonary embolismiv. ARDSv. Metabolic acidosis

Bradypnoea: It is a decrease in the rate of respiration.Conditions causing bradypnoea are:a. Alkalosisb. Hypothyroidism (myxoedema)c. Narcotic drug poisoningd. Raised intracranial tension.

Hyperpnoea: It is an increase in depth of respiration.Conditions causing hyperpnoea are:a. Acidosisb. Brainstem lesionc. Hysteria.

RhythmInspiration: It is an active process brought about by thecontraction of the external intercostal muscles and thediaphragmExpiration: It is a passive process and it depends uponelastic recoil of the lungs.Accessory muscles of inspiration are the scaleni,trapezius and pectoral muscles.Accessory muscles of expiration are abdominalmuscles and latissimus dorsi.

Abnormal Breathing PatternsAbnormal breathing patterns may be regular or irregular

Regular abnormal breathing patternsa. 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.

Irregular abnormal breathing patternsa. Biots breathing: It is characterised by apnoea between several shallow or few deep inspirations. It occurs in meningitisb. Ataxic breathing: It is characterised by irregular pattern of breathing where both deep and shallow breaths occur randomly. It occurs in brainstem lesions

c. Apneustic breathing: It is characterised by pause atfull inspiration, alternating with a pause in expiration,lasting for 2 to 3 seconds. It occurs in pontinelesions

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

The position of the trachea is confirmed by 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

Palpation for Position of trachea

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 cmIn severe emphysema, it is less than 1 cm

General Restriction of Expansiona. COPDb. Extensive bilateral diseasec. Ankylosing spondylitisd. Interstitial lung diseasee. Systemic sclerosis (hide bound chest).

Asymmetrical Expansion of the Chesta. Pleural effusionb. Pneumothoraxc. Extensive consolidationd. Collapsee. Fibrosis.In all these above conditions, diminished expansion occurs on the affected side.

Assessing Symmetry of Chest Expansion

anterior thoracic expansion

upper thoracic expansion

posterior thoracic expantion

It is a vibration felt by the hand when the patient is asked to repeat ninety-nine or one-one-one, by putting the vocal cord into action.

Identical areas of the chest are compared on both sides.

It is felt with the flat of the hand or with the ulnar border of the hand for accurate localization.

It is increased in consolidation. It is decreased in pleural effusion

Palpation for Vocal fremitus (VF)

Tenderness over the Chest Wall

It may be due to:1. Empyema2. Local inflammation of parietal pleura, soft tissue andosteomyelitis3. Infiltration with tumor4. Non-respiratory cause (amoebic liver abscess).

Percussion Percussion for the Lung fields

Cardinal Rules of Percussion

a. 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 pocketsb. The plexor: The middle or the index finger of the examiner’s right hand is used to hit the middle phalanx of the pleximeterc. The percussion movement should be sudden, originating from the wrist. The finger should be removed immediately after striking to avoiddampingd. Proceed from the area of normal resonance to the area of impaired or dull note, as the difference is then easily appreciatede. The long axis of the pleximeter is kept parallel to the border of the organ to be percussed.

Direct percussion—clavicle

Anterior Chest WallClavicle: Direct percussion is used and percussion isdone 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 5th rib downwards in the midclavicular line.

Lateral Chest WallFourth to seventh intercostal spaces.Liver dullness can be percussed from the right 8th rib downwards in the midaxillary line.

Posterior Chest Walla. Suprascapular (above the spine of the scapula)b. Interscapular regionc. Infrascapular region up to the eleventh rib.Liver dullness can be percussed from the right 10th rib downwards in the midscapular line.

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.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.

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.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.Identifyany 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 soundsdirectly from the trachea or main bronchi.

Vesicular breath sounds low pitched, rustling in

nature produced by attenuating

and filtering effect of the lung parenchyma.

Duration of the inspiratory phase is longer than the expiratory phase in a ratio of 3 : 1.

There is no pause between the end of inspiration and the beginning of expiration.

Bronchial breath sounds It is loud and high pitched,

with an aspirate or guttural quality.

It is produced by passage of air through the trachea and large bronchi

The duration of inspiration is shortened whereas that of expiration is prolonged or equal

There is a pause between inspiration and expiration.

Types of Bronchial Breathinga. Tubularb. Cavernousc. Amphoric.

Added soundsAdded sounds are 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.

NEW Terms OLD Terms

Definations

coarse crackles

râles non-musical, interruptedshort, explosive sounds often described as bubbling or clicking.fine crackles crepitation

swheezes rhonchi Continuous musical sounds

associated with airway narrowing.

Vocal resonance is the detection of vibrations transmitted to the chest from the vocal cords as the patient repeats a phrase, usually the words ‘ninetynine’assess the quality and amplitude of vocal resonance.Typesa. Bronchophony: Voice sounds appear to be heard near the

earpiece of stethoscope and words are unclear, e.g. consolidation, cavity communicating with a bronchus,

b. Aegophony: Voice sound has a nasal or bleating quality. On saying ‘E’, it will be heard as ‘A’ (E to A sign),

e.g. consolidation, cavity.c. Whispering pectoriloquy: The patient is asked to whisper words at the end of expiration, and this whispered voice individual syllables are recognised clearly,e.g. pneumonic consolidation, cavity communicating with a bronchus

Examination of RSName:Age:Sex:Address:Occupation:

1) General Physical Examination:Young patient moderately built and moderately nourished, well oriented to time place and person, conscious and cooperativePallorIcterusCyanosisClubbingEdemaLymphadenopathy

TemperaturePulse

Respiratory RateBPJVP

3) Examination of the ChestInspection: Trachea appears Central in Position Shape of the chest is elliptical, Bilaterally symmetrical Movement of the chest is equal on both sides and normal Respiratory Movement

Rate : 14 – 18 Breaths per minute Rhythm : Regular Depth : Normal Type : Abdominothoracic /

Thoracoabdominal Accessory muscles of Respiration not in use No skeletal deformity seen Apical impulse not seen/seen at Left 5th ICS medial to

MCL No dilated or engorged veins present No scars or swelling or other visible pulsations seen

Palpation: Apical Impulse felt at Left 5th ICS medial to MCL and is of

Normal Character Trachea centrally Placed (slightly deviated to right side) Expansion of the chest is normal and symmetrical,

expansion is more at the base compared to apex and sides of chest

Measurement of the Chest Expansion Transverse Diameter :

___cm Anteroposterior Diameter :

___cm Right/Left Hemithorax :

___cm Chest circumference in expiration : ___cm Chest circumference at full inspiration : ___cm Chest expansion :

___cm No tenderness present

Area Right LeftSupraclavicular area Equal on both sidesInfraclavicular area Equal on both sidesMammary region Equal on both sidesInframammary region

Equal on both sides

Axillary region Equal on both sidesInfra-axillary region Equal on both sidesSuprascapular region

Equal on both sides

Interscapular region Equal on both sidesInfrascapular region Equal on both sides

Vocal fremitus (VF)

Percussion:Area Right LeftSupraclavicular area Resonant ResonantInfraclavicular area Resonant ResonantMammary region Resonant DullnessInframammary region

Dullness(5th ICS onwards)

Dullness

Axillary region Resonant ResonantInfra-axillary region Resonant ResonantSuprascapular region

Resonant Resonant

Interscapular region Resonant ResonantInfrascapular region Resonant Resonant

Auscultation Breath Sounds

Area Right LeftSupraclavicular area Vesicular VesicularInfraclavicular area Vesicular VesicularMammary region Vesicular VesicularInframammary region

Vesicular Vesicular

Axillary region Vesicular VesicularInfra-axillary region Vesicular VesicularSuprascapular region

Vesicular Vesicular

Interscapular region Vesicular VesicularInfrascapular region Vesicular Vesicular No added Sounds

Area Right LeftSupraclavicular area Equal on both sidesInfraclavicular area Equal on both sidesMammary region Equal on both sidesInframammary region

Equal on both sides

Axillary region Equal on both sidesInfra-axillary region Equal on both sidesSuprascapular region

Equal on both sides

Interscapular region Equal on both sidesInfrascapular region Equal on both sides

Vocal Resonance (VR)

Report: Examination of the respiratory system of the subject is clinically normal