INSPECTION1. 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 Fibrothorax

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

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

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

2. 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

Contd..3. Apical Impulse: Stand on the right side of the patient and look

tangentially over the precordium Helps to note the precordial shift

4. Tracheal deviation: Ask the patient to look forward an look for any

deviation

Contd..5. Respiration: Rate Rhythm Type

6. Venous Prominance: Superior venacava syndrome: Presence of distended

vein over the chest wall

Contd..7. Retraction/Fullness of intercostal space: Abnormal retraction:

Severe asthma COPD Upper airway obstruction

Fullness of intercostal space: Pleural effusion Haemothorax pneumothorax

Contd..8. Level of nipple: Whether both the nipple are at the same level or not

9. Skin over the chest:• Cold abscess• Ulcer• Swelling• Scar mark

Contd..10. 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

PALPATION1. Surface temperature

2. Tenderness:• Rib tenderness: Trauma, fracture • Intercostal tenderness: Liver abscess, empyema thoracis

3. Corroboration of inspetory findings

4. Spinal deformity

Contd..5. 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

Contd..• Shift of trachea:

To the same side

To the opposite side

Fibrosis of lung Massive pleural effusion

Collapse of lung Pneumothorax

pneumonectomy Hydropneumothorax

Contd..6. 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

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

Contd.. Posterior thoracic movement

Perform at the infrascapular region

Contd..7. 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

Contd.. Decreased chest expansion

Unilateral Bilateral

Pleural effusion Emphysema

Pneumothorax Hydrothorax

Collapse of lung Bronchial asthama

Fibrosis of lung Myasthenia gravis

Contd..7. 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

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

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

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

Contd..i. For anterior percussion: Patients should sit erect with hands by his side

ii. 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

iii. Lateral percussion: The patient should sit with his hand held over the head

Area of percussioni. Anterior chest wall:

a) Clavicle: Direct percussion Percussion is done within middle 1/3rd of clavicle

b) Supraclavicular region It is a band of resonance 5-7cm size over the

supraclavicular fossa

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

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

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

Contd..iii. Posterior chest wall

a) Suprascapularb) Interscaularc) Infrascapular region upto the 11th ICS

Types of percussion note

Lesion

1. Tympanitic Hollow viscus2. Sub tympanitic Above the level of pleural

effusion3. Hyper-resonant Pneumotharax4. Resonant Normal lung5. Impaired Pulmonary fibrosis6. Dull Consolidation,collapse7. Stony dull Pleural effusion,haemothorax

AUSCULTATIONPreliminaries 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

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 6th rib, laterally from axilla to the 8th rib and posteriorly down to the level of the 11th rib

In each area listen to the quality and amplitude of breath sound

Contd..Position of the patient: Sitting position

Auscultatory area:

i. Anterior: From an area above the clavicle down to 6th rib

ii. Axilla: Area upto 8th rib

iii. Posterior: Above the level of spine of scapula down to 11th rib

Contd..1. 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

Contd..i. 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.

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.

Contd..Condition with diminished vesicular breath sound:

Bronchial asthma Tumor Pleural effusion Pleural thickeing Emphysema

Contd..ii. 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.

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).

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  3rd 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.

Contd..Types of bronchial breathing:a. Tubular: They are high pitched and present in:

pneumonic consolidation collapse lung

b. Cavernous: They are low pitched and heard in the presence of thick walled cavity with a communicating bronchusc. Amphoric: They are low pitched, with a high tone and metallic quality and present in:

Bronchopleural fistula Tension pneumothorax

Contd..Causes of absent breath sound:

Pleural effusion(massive)

Thickned pleura

Pneumothorax

Collapsed lung

Contd..2. Added sounds

i. 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

Contd..Crackles may be: Early inspiratory: Chronic bronchitis Mid inspiratory: Bronchiectasis Late inspiratory: Asbestosis,pulmonary

fibrosis,pneumonitis Expiratory: Chronic bronchitis

Mechanism of crackles: Bubbling or flow of air through secretion in the

bronchial level

Contd..ii. 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

Contd..iii. 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.

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)

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

Contd..3. Vocal resonance: It is a voice sound heard with the chest piece of stethoscopei. Increased vocal resonance:

Consolidation Collapse with patent bronchus Open pneumothorax

ii. Decreased vocal resonance Pleural effusion Pneumothorax Emphysema

Contd..4. 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

5. 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