Physical Examination in Respiratory System

1. Physical Examination in Respiratory System Zhao Li, M.D.

2. Sternal angle Spinous process subscapular angle xiphoid Intercostal space Costalspinal angle Skeletal landmarks

3. Suprasternal fossa Supraclavicular fossa Infraclavicular fossa Sternal line Sternal angle Parasternal line Anterior midline Midclavicular line epigastric angle Anterior imaginary lines and landmarks

4. Posterior axillary line Anterior axillary line Midaxillary line Lateral imaginary lines

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

6. Anterior view of lobes

7. Posterior view of lobes

8. Right lateral view of lobes

9. Left lateral view of lobes

10. Pectus excavatum Barrel chest Kyphosis Thoracic deformity

11. Inspection(1) • Respiratory movement • Abdominal breathing: male adult and child • Thoracic breathing: female adult

12. Inspection(2) • Respiratory rate: 16-18 f/min • Tachypnea: >20 f/min • Bradypnea: <12 f/min

13. Inspection(2) • 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)

14. 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

15. Palpation • Thoracic expansion • Massive hydrothorax, pneumonia, pleural thickening, atelectasis • Vocal fremitus (tactil fremitus) • Pleural friction fremitus • Cellulose exudation in pleura due to pleurisy • Holding breathing disappeared • Tuberculous pleurisy, uremia, pulmo embolism

16. Percussion

17. 1. Method • Mediate • Pleximeter: distal inter-phalangeal joint of left middle finger • Plexor: right middle finger tip • Immediate • Order • Up to down, anterior to posterior

18. 2. Affected factors • Thickness of thoracic wall • Calcification of costal cartilage • Hydrothorax • Containing gas in alveoli • Alveolar tension • Alveolar elasticity

19. 3. Classification • Resonance • Normal • Hyperresonance • Emphysema • Tympany • Cavity , pneumothorax • Dullness • Hydrothorax, atelectasis • Flatness • Massive Hydrothorax, massive atelectasis

20. 4. Normal sound Lung’s sound in percussion • Resonance • Slight dullness in some areas (upper, right, back) due to thickness of muscles and skeletons

21. 4. Normal sound 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 line, scapular line, respectively • Downward: emphysema • Upward: atelectasis, intraabdominal pressure increased

22. Along the scapular line To percuss bottom of lung, marking 6-8 cm To ask the pat. to inspire deeply and hold Shifting range of bottom of lung To percuss bottom of lung, marking To ask the pat. to expire deeply and hold To percuss bottom of lung, marking To measure the dist. between upper and lower lines 4. Normal sound • Shifting range of bottom of lung • Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia • Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphragmatic paralysis

23. 5. 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

24. 5. Abnormal sound Dullness or flatness • Decreased containing gases in alveoli • Pneumonia • Atelectasis? • TB • Pulmo. embolism • Pulmo. edema • Pulmo. fibrosis

25. 5. Abnormal sound Dullness or flatness • No gases in alveoli • Tumor • Pulmo. Hydatid (肺包虫) • Pneumocystis (肺囊虫) • Non-liquefied lung abscess • Others • Hydrothorax • Pleural thickness

26. 5. 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

27. 5. Abnormal sound • Tympanitic dullness (浊鼓音) • Decreased tension and gases in alveoli • Atelectasis • Congestive or resolution stage of pneumonia • Pulmo. edema

28. Garland’s triangle area (tympanitic dullness) Damoiseau’s curve Grocco’s triangle area (dullness) 5. Abnormal sound • Special areas on percussion in moderate hydrothorax

29. Auscultation

30. Order of auscultation

31. Sound of auscultation • Normal breath sound • Abnormal breath sound • Adventitious sound • Vocal resonance (语音共振) • Pleural friction rub

32. Bronchial Bronchovesicular Bronchial Bronchovesicular 1. 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 beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung • Vesicular breath sound • Most area of lungs

33. 2. Abnormal breath sound • Abnormal vesicular breath sound • Abnormal bronchial breath sound • Abnormal bronchovesicular breath sound

34. Abnormal vesicular breath sound(1) • Decreased or disappeared • Limited movement of thoracic wall • Respiratory muscle weakness • Obstruction of airway • Compressed atelectasis • Hydrothorax or pneumothorax • Abdominal diseases: ascites, large tumor • Increased • Increased movement of respiration • Exercise, fever, anemia, metabolic acidosis, compensation (single lung)

35. Abnormal vesicular breath sound (2) • Prolonged expiration ___ uncompleted obstructionand / or decreased alveolar elasticity • Bronchitis • Asthma • emphysema

36. Abnormal vesicular breath sound (3) • Cogwheel breath sound • TB • Pneumonia • Coarse breath sound ____ not smooth in airway due to swollen or exudation • bronchitis • Early stage of pneumonia

37. Abnormal bronchial breath sound(tubular breath sound) • Bronchial breath sound appears in the area where vesicular breath sound is supposed to appear because of increased sound transmission or resonance. • Consolidation: lobar pneumonia (consolidation stage) • Large cavity: TB, lung abscess • Compressed atelectasis: hydrothorax, pneumothorax

38. Abnormal bronchovesicular breath sound • Bronchovesicular breath sound appears in the area where vesicular breath sound is supposed to appear. • The lesion is relatively smaller, deeper or mixed with normal lung tissue. • bronchopneumonia • TB • Early stage of lobar pneumonia • Upper area of hydrothorax

39. 3. Adventitious sound • moist Crackles • Rhonchi (wheezes)

40. Moist crackles Mechanism During inspiration, air flow passes thin secretion in the airway to rupture the bubbles, or to open the collapse of bronchioli due to adhesion by secretion.

41. Characteristics of crackles • Adventitious sound • Intermittent • Appeared in phase of inspiration or early expiration • Constant in site • Unchanged in character • Medium and fine crackles exist meantime • Less or disappeared after cough sometimes

42. Classification of moist crackles(1) • According to intensity of the sound • Loud moist crackles • Slight moist crackles

43. Classification of moist crackles(2) • According to diameter of the airway crackles appeared • Coarse: trachea, main bronchi, or cavity • Bronchiectasis, pulmo. edema, TB, lung abscess, coma (wheezy phlegm, 痰鸣) • Medium: bronchi • bronchitis, bronchopneumonia

44. Classification of moist crackles(3) • Fine: bronchioli • Bronchiolitis, Pneumonia, pulmo. congestion, pulmo. embolism • Velcro: • Interstitial lung disease • Crepitus: • Bronchiolitis, alveolitis, early pneumonia (congestion), elder subject, pat. lying in bed for long time

45. Site of crackles • Local: local lesion • Pneumonia • TB • Bronchiectasis • Both bases • Pulmo. congestion • Bronchopneumonia, • Full fields • Acute pulmo. Edema • Severe bronchopneumonia

46. Rhonchi (wheezes) Mechanism The turbulent flow is formed in trachea, bronchi or bronchioli due to airway narrow or incomplete obstruction. Causes • Congestion • Secretion • Spasma • Tumor • Foreign subject • Compression (lymph node, mediastinal tumor)

47. Characteristics of rhonchi • Adventitious sound • High pitch • Dominance in phase of expiration • Variable intensity, character, site or spread • Wheezing (appeared in main bronchi)

48. Classification of rhonchi • Sibilant (哨笛音，高调) • Bonchioli, smaller bronchi • Sonorous (鼾音，低调) • Trachea, main bronchi

49. Site of rhonchi • Both fields • Asthma • Chronic bronchitis • Acute left heart failure (cardiac asthma) • Local site • Tumor • Endobronchial TB

50. Vocal resonance Increased sound transmission due to changed density of lung tissue • 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 Increased density of lung tissue: Consolidation vs Atelectasis