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RESPIRATORY EXAMINATION

SYMPTOMS & SIGNS


• COUGH
COUGH
DEFINITION
• Reflex
• Forceful expiration against Closed glottis
• Helps clear airways

MECHANISM OF COUGH
• Contraction of respi muscles against Closed glottis  ↑ Pintrathoracic 
• Opening of glottis w Forced expiration at very high air flow rate
TYPES OF COUGH DISEASES
DRY COUGH • ILD
• Mediastinal lesions
• Pleural disorders
PRODUCTIVE COUGH • Chr bronchitis
• Pulmonary TB
• Suppurative lung disease
BARKING COUGH • Diseases w epiglottal involvement
• Hysterical individuals
• Nervous individuals
BRASSY COUGH • Intrathoracic space occupying lesions
• Cough + Metallic sound due to Compression of trachea
BOVINE COUGH • Tumors pressing on recurrent laryngeal n
• Cough w Loss of its explosive nature
PROLONGED PAROXYSMAL COUGH • Chr bronchitis
• Whooping cough
SHORT COUGH • URTI (i.e. Common cold)
ANATOMICAL LANDMARKS
• TRACHEAL BIFURCATION
• ANT : At level of angle of Louis
• POST : Btw 4th & 5th thoracic spines
• ANGLE OF LOUIS/STERNAL ANGLE
• Transverse bony ridge at junc of
• Body of sternum &
• Manubrium sterni
• MAJOR INTERLOBAR FISSURE
• MINOR INTERLOBAR FISSURE
EXAMINATION OF RESPIRATORY SYSTEM
• INSPECTION OF UPPER RESPI TRACT
• INSPECTION OF LOWER RESPI TRACT
INSPECTION OF UPPER RESPI TRACT
• NOSE
• DNS
• Nasal polyps
• IN
• Allergic asthma
• Cystic fibrosis
• Wegener’s granulomatosis
• ORAL CAVITY
• Oral hygiene

• Dental caries
• Tonsils
• PHARYNX
• Post-nasal drip
INSPECTION OF LOWER RESPIRATORY TRACT
• COMPARED ON BOTH SIDES IN • RESPIRATORY RATE
FOLLOWING AREAS • RESPIRATORY RHYTHM
• Supraclavicular
• Infraclavicular
• Mammary region • TYPE OF BREATHING
• Axillary region • SHAPE & SYMMETRY OF CHEST
• Infra-axillary region
• Suprascapular region • SKIN
• Interscapular region
• Infrascapular region • MEDIASTINUM
• POSITION OF TRACHEA
• POSITION OF APEX BEAT
• MOVEMENTS OF CHEST
RESPIRATORY RATE
• NORM • ABNORM
• ADULTS : 16-20 respirations/min • BRADYPNEA - ↓ RR
• CHILDREN : 40 respirations/min • Brain tumour
• Hypothyroidism (i.e. myxedema)
• Narcotic poisoning
• RESPIRATORY RATE : PULSE RATE
• Opium
= 1:4
• TACHYPNEA - ↑ RR
• Excitement/Exertion
• Anemia
• Acidosis & Anoxemia
• Fever
• Pain while breathing
• Pleurisy
• Poisoning
• Respiratory cond
• Acute pulmonary edema
• ARDS
• Pneumonia
• Pulmonary embolism
• DYSPNEA - BREATHLESSNESS
• HYPERPNOEA - ↑ DEPTH OF RESPIRATION
AMERICAN THORACIC SOCIETY (ATC) SCALE FOR
DYSPNEA
GRADE DEGREE DESCRIPTION
0 NONE NOT Troubled by shortness of breath
• On level/Uphill
1 MILD Troubled by shortness of breath
• On level/Uphill
2 MODERATE Walk slower than persons of same age
3 SEVERE Stops after walking
• Few minutes on level ground OR
• 100 yards
4 VERY SEVERE Breathless on dressing/undressing OR
Too breathless to leave hse
MODIFIED MEDICAL RESEARCH COUNCIL (MMRC)
SCALE FOR DYSPNEA
GRADE DESCRIPTION
1 Breathlessness w strenuous exercise
2 Breathless when
• Hurrying on level OR
• Walking uphill
3 Walk slower than persons of same age
4 Stops after walking
• Few minutes on level ground OR
• 100 yards
5 Breathless on dressing/undressing OR
Too breathless to leave hse
RESPIRATORY RHYTHM
• LOOK AT HANDWRITTEN NOTES
MUSCLES OF INSPIRATION
MUSCLES OF EXPIRATION
ABNORMAL RESPIRATORY PATTERNS
TYPE OF BREATHING
• NORM • ABNORM
• MALES : Abdominothoracic • ABDOMINAL BREATHING
• Abdominal movements more prominent • Collapse of lung
• FEMALES : Thoracoabdominal • Pleurisy
• Thoracic movements more prominent • THORACIC BREATHING
• Diaphragmatic paralysis
• Peritonitis
• Severe ascites
SHAPE & SYMMETRY OF CHEST
• EXAMINATION SEQUENCE
• Sit pt
• Over edge of bed/
• On chair
• Look at chest
• Observe AP & Lat diameter relationship
• NORM
• CS
• Elliptical
• AP diameter < Transverse diameter
• 5:7
• Bilaterally sym

• Interspaces = Broader anteriorly


• Subcostal angle = 90°
• More acute in males
• ABNORMAL SHAPES & SYMMETRY OF CHEST
• BARREL SHAPED CHEST
• PECTUS CARINATUM (PIGEON CHEST)
• PECTUS EXCAVATUM (FUNNEL CHEST)
• SPINAL DEFORMITIES

• FLAT CHEST
• BARREL SHAPED
• AP > Lat diameter (ML), AP : Lat diameter = 1:1 (A)
• MECH : Lung hyperinflation
• IN
• PHYSIOLOGICAL : Infancy, Old age
• PATHOLOGICAL : Severe COPD
• PECTUS CARINATUM (PIGEON CHEST)
• Localised PROMINENCE of Sternum + adjacent Costal cartilages
• + INDRAWING of Ribs
• = Symmetrical horizontal grooves (i.e. Harrison’s sulci) above costal margin
• MECH
• Lung hyperinflation + Repeated vigorous contractions of diaphragm
• While bony thorax is in pliable prepubertal state
• DIAPHRAGM GOES DOWN  INTRATHORACIC PRESSURE INCREASE  ATM P PUSH RIBS IN
• IN
• Childhood Asthma
• Osteomalacia, Rickets

• Marfan’s syndrome

• PECTUS EXCAVATUM (FUNNEL CHEST/COBBLER’S CHEST)


• DEVELOPMENTAL DEFORMITY
• Localised DEPRESSION of Lower end of Sternum
• NOTE
• Pt ASYMPTOMATIC BUT concerned abt APPEARANCE
• IN SEVERE CASES
• Heart displaced to lt
• Ventilatory capacity ↓
• SPINAL DEFORMITIES
• KYPHOSIS – Exagerrated ant curvature of spine
• SCOLIOSIS - Exagerrated lat curvature
• KYPHOSCOLIOSIS
• IN
• Poliomyelitis
• Spinal tuberculosis
• NOTE
• ↓ Ventilatory capacity  ↑ Work of breathing
• Pt develop at an early age
• Ventilatory failure w CO2 retention
• Cor pulmonale

• FLAT CHEST
• AP : Transverse diameter = 1:2
• IN
• Pulmonary TB
• Fibrothorax
• RICKETY ROSARY
• Bead like enlargement of costochondral junc
• IN : Rickets
• SCORBUTIC ROSARY
• Sharp angulation of ribs
• W or W/O Beading/Rosary formation
• MECH : Backward displacement/Pushing in of sternum
• IN : Vit C def
SKIN
• VASCULAR ANOMALIES
• IN : Dil venous vascular channels of SVCO
• S.C. LESIONS
• METASTATIC TUMOR NODULES, LIPOMAS

• INTERCOSTAL SCAR
• IN : Drained Pneumothorax, Pleural effusion, Empyema
• EMPYEMA NECESSITANS
• DISCHARGING SINUS
• IN : TB
MEDIASTINUM
POSITION OF TRACHEA
• TRAIL’S SIGN
• Undue prominence of clavicular head of sternomastoid
• On side to which trachea deviated
• MECHANISM
• Pretracheal fascia encloses clavicular head of sternomastoid on both sides
• If trachea shifted to one side
•  Pretracheal fascia covering sternomastoid on tht side relaxes
•  ∴ Clavicular head on side of tracheal deviation more prominent

POSITION OF APEX BEAT


• Apex beat shifts to side of mediastinal shift
MOVEMENTS OF CHEST
• LOOK AT PALPATION
PALPATION
• MEDIASTINUM
• CONFIRMATION OF POSITION OF TRACHEA
• CONFIRMATION OF APICAL IMPULSE
• MOVEMENTS OF CHEST
• MEASUREMENT OF CHEST EXPANSION
• ASSESS SYMMETRY OF CHEST EXPANSION
• ASSESS ANT THORACIC MOVEMENT
• ASSESS POST THORACIC MOVEMENT
• ASSESS UPPER THORACIC MOVEMENT
• MOVEMENTS OF ABDOMEN
• FREMITUS
• FRICTION FREMITUS
• TACTILE FREMITUS
• VOCAL FREMITUS
• TENDERNESS
• OTHER VIBRATIONS
MEDIASTINUM
CONFIRMATION OF POSITION OF TRACHEA
• PROC
• Flex neck slightly so chin remains in midline
• Insert rt index finger in suprasternal notch
• Feel tracheal ring
• RESULT
• Slight shift of trachea to right = NORM
• ALSO
• Measure dist btw suprasternal notch & cricoid cartilage
• NORM = 3-4 finger breadths
• Less = LUNG HYPERINFLATION
• TRACHEAL TUG-OLLIVER’S SIGN
• INSPIRATORY TRACHEAL DESCENT
CONFIRMATION OF APICAL IMPULSE
SHIFT CONDITION
APICAL IMPULSE • Enlargement of ventricle
• Funnel-shaped depression of sternum
• Scoliosis

• Diseases of lung altering position of mediatinum


TRACHEA ‘PUSHED’ TO OPPOSITE SIDE • Pleural effusion
• Pneumothorax
• Tumour
TRACHEA ‘PULLED’ TO SAME SIDE • Collapse of lung
• Fibrosis
TRACHEA SHIFTED TO SAME SIDE • Effusion/Empyema following pre-existing fibrosis
IN PRESENCE OF PLEURAL EFFUSION • Mass w Collapse & Pleural effusion
• Mesothelioma
MOVEMENTS OF CHEST
MEASUREMENT OF CHEST EXPANSION
• INSTRUMENT : Inch tape
• PROC
• Measure circumference of chest
• Then measure expansion of chest w deep inspiration
• MALE : Measure at level of nipple
• FEMALE : Measure below breast
• RESULT
• NORM EXPANSION = 5-8 cm
• < 1 cm = SEVERE EMPHYSEMA
• NON-RESPIRATORY CAUSE OF POOR CHEST EXPANSION : Ankylosing spondylitis
ASSESS SYMMETRY OF CHEST EXPANSION
• ASSESS ANT THORACIC MOVEMENT
• PROC
• Stand in front pt
• Place finger tips of both hands on either side of pts rib cage
• NOTE
• Thumbs
• Almost meet in midline
• Hover just off chest so can move freely w respiration
• Compare degree of expansion on both sides
• During deep breath

• RESULT
• UNILAT ↓ EXPANSION
• Lobar/Lung collapse
• Pleural effusion
• Pneumothorax
• Unilat fibrosis
• BILAT ↓ EXPANSION
• Severe COPD
• Diffuse pulmonary fibrosis
• ASSESS POST THORACIC MOVEMENT
• PROC
• Stand behind pt
• Place finger tips of both hands on either side of pts rib cage
• Compare degree of expansion on both sides
• During deep breath

• RESULT
• UNILAT ↓ EXPANSION
• Lobar/Lung collapse
• Pleural effusion
• Pneumothorax
• Unilat fibrosis
• BILAT ↓ EXPANSION
• Severe COPD
• Diffuse pulmonary fibrosis
• ASSESS UPPER THORACIC MOVEMENT
• PROC
• Stand behind pt
• Place both hands over pts supraclavicular fossae
• Compare extent of upward movement of hands on both sides
• During quiet respiration

• RESULT
• UNILAT ↓ EXPANSION
• Lobar/Lung collapse
• Pleural effusion
• Pneumothorax
• Unilat fibrosis
• BILAT ↓ EXPANSION
• Severe COPD
• Diffuse pulmonary fibrosis
MOVEMENTS OF ABDOMEN
• PROC
• Pt supine
• Look at movement of abdomen during inspiration

• RESULTS
• NORM : Outward movement
• PARADOXICAL INWARD MOVEMENT OF ABDOMEN/CHEST
• Severe COPD
• Diaphragmatic paralysis
• Fracture of Series of ribs/Sternum
FREMITUS
• FRICTION FREMITUS
• Palpable pleural rub
• TACTILE FREMITUS
• Palpable added sounds
• NOTE : Rhonchi better felt than Crackles
• VOCAL FREMITUS
• PROC
• Ask pt to repeat ninety-nine/one-one-one
• Feel vibration by hand
• Flat of hand/
• Ulnar border of hand
• Compare indentical areas of chest on both sides
• RESULT
• ↑ = Consolidation
• ↓ = Pleural effusion
TENDERNESS
• OVER CHEST WALL
• Empyema
• Infiltration w tumor
• Local inflammation
• Osteomyelitis
• Parietal pleura
• Soft tissue

• Amoebic liver abscess (i.e. Non-respiratory cause)


• OVER COSTAL CARTILAGES
• Costochondritis of Tietze’s syndrome
• OVER RIBS
• Fracture
• Pulmonary infarct below tht rib
PERCUSSION
• GENERAL PRINCIPLES
• CARDINAL RULES OF PERCUSSION
• AREAS OF PERCUSSION
• POSITION OF PT
• PERCUSSION NOTE
• PERCUSSION ON RT SIDE
• PERCUSSION ON LT SIDE
• SPECIAL FEATURES OF CLINICAL IMP
• LIMITATIONS OF PERCUSSION
GENERAL PRINCIPLES OF PERCUSSION
CARDINAL RULES OF PERCUSSION
• PLEXIMETER
• Middle finger of lt hand
• Opposed tightly over chest wall/intercostal spaces
• Long axis parallel to border of organ
• Other fingers NOT touch chest wall
• PLEXOR
• Index/Middle finger of rt hand
• Hit middle phalanx of pleximeter
• PERCUSSION MOVEMENT
• Originate from wrist
• Sudden
• Finger removed immediately after striking
• To avoid damping
• PROCEED
• Area of normal resonance  Area of dull/impaired note
AREAS OF PERCUSSION POSITION OF PT
• ANT CHEST WALL • SITTING (BEST)
• Clavicle • ANT PERCUSSION
• Direct percussion on Med 1/3rd of clavicle • Sit erect
• Supraclavicular • Hands by side
• i.e. Kronig’s isthumus) • POST PERCUSSION
• Head bent forwards
• Infraclavicular • Hands over opposite shoulders
• 2nd-6th Intercostal spaces • Keeps 2 scapulae further away
• Percussion note CANNOT be compared • ∴ More lung available for percussion
• Due to relative cardiac dullness on lt side • LAT PERCUSSION
• Sit erect
• POST CHEST WALL • Hands over head
• Suprascapular
• i.e. Above spine of scapula • SUPINE (NOT DESIRABLE)
• Interscapular region • As percussion note alters due to underlying
structure
• Infrascapular region
• Up to 11th rib
PROC OF PERCUSSION
• LAT CHEST WALL
• 4th-7th Intercostal spaces • Start percussion at apices of lung
• Compare both sides
• Proceed downwards
PERCUSSION NOTE CORRESPONDING AREA/LESION
DULL NORMAL HEART, LIVER, SPLEEN
• Collapse
• Consolidation
• Pleural thickening

RESONANT* NORMAL LUNG


• BA
• Chr bronchitis
• Diffuse emphysema
• ILD

TYMPANIC HOLLOW VISCUS


• Drum like resonance • Emphysema
• Pneumothorax
PERCUSSION NOTE CORRESPONDING AREA/LESION
STONY DULL • Empyema
• Devoid of resonance/Extreme dullness • Parenchymal lung disorder w pleural thickening
• Fluid dampens vibrations • Pleural effusion
HYPER RESONANT • Pneumothorax
SUBTYMPANIC @ SKODIAC RESONANCE • Above level of pleural effusion
• Hyper resonant note
• Boxy quality
BELL TYMPANY • Pneumothorax (LOOK AT COIN TEST BELOW)
• High pitched metallic sound
IMPAIRED • Cavity w surrounding Fibrosis
• Air in alveoli ↓  Lung fail to vibrate on percussion • Pulmonary fibrosis
PERCUSSION ON RT SIDE
• LIVER DULLNESS
• NORM
• In midclavicular line
• Rt 5th IS  Rt Costal margin
• ABNORM
• In 4th space = Amoebic/Pyogenic liver abscess, Collapse of lower lobe of lung, Diaphragmatic paralysis
• In 6th space = Emphysema, Rt side pneumothorax, Terminal cirrhosis

• TIDAL PERCUSSION
• AIM : Differentiate Rt side parenchymal/pleural disorder from Upward enlargement of liver
• PROC : Percuss on deep inspiration
• RESULT
• Previous Dull note in midclavicular line of rt 5th IS  Resonant = DULLNESS WAS DUE TO LIVER
• As liver pushed down by rt hemidiaphragm on deep inspiration
• Dullness persists = RT SIDED PARENCHYMAL/PLEURAL PATHOLOGY
PERCUSSION ON LT SIDE
• CARDIAC DULLNESS
• NORM : In 3rd & 4th lt parasternal line & 5th lt midclavicular line
• ABNORM : Area of dullness
• ↑ : Cardiomegaly
• ↓ : Emphysema, Lt sided pneumothorax
PERCUSSION ON LT SIDE
• TRAUBE’S SPACE
• SURF ANATOMY
• Draw 2 parallel vertical lines
• 1 from lt 6th costochondral jun
• Another from 9th rib in mid axillary line
• Connect 2 lines
• Above from lt 6th costochondral junc to 9th rib in mid axillary line
• Below along costal margin
• Forms semilunar space
• BOUNDARIES OF TRAUBE’S SPACE
• ABOVE : Lt lung resonance
• BELOW : Lt costal margin
• RT SIDE : Lt lobe of liver
• LT SIDE : Spleen
• CONTENT : Fundus of stomach
• ∴ Tympanic on percussion due to gas
• OBLITERATION  DULL NOTE IN
• Massive pericardial effusion
• Lt side pleural effusion
• Enlarged lt lobe of liver
• Massive splenomegaly
• Full stomach
• Fundal growth
• SHIFTED UPWARDS IN
• Lt diaphragmatic paralysis
• Lt lower lobe collapse
• Lt lung fibrosis
SPECIAL FEATURES OF CLINICAL IMP
• COIN TEST
• PROC
• Coin placed flat on chest
• Strike w another coin
• Auscultate back of chest on same side
• RESULT : Bell-like/Metallic sound heard
• Resembles ‘hammer on an anvil’ sound
• CAUSE : Pneumothorax
• KRONIG’S ISTHMUS
• BAND OF RESONANCE 5-7 CM OVER SUPRACLAVICULAR FOSSA
• BOUNDARIES
• MED : Scalenus muscle of neck
• LAT : Acromion process of scapula
• ANT : Clavicle
• POST : Trapezius
• PROC : Percuss by standing behind pt
• RESULT :
• NORM : Resonant lung apices
• ABNORM
• Hyper resonance = Emphysema
• Impaired resonance = Maligancy in lung apex, Pulmonary TB
SPECIAL FEATURES OF CLINICAL IMP
• PERCUSSION MYOKYMIA
• PERCUSSION TENDERNESS
• Empyema
• Inflammation of parietal pleura
SPECIAL FEATURES OF CLINICAL IMP
• SHIFTING DULLNESS
• AIM : Demonstrate shift of fluid in hydropneumothorax/pleural effusion
• DEMONSTRATED BY PERCUSSING
• Dull area in axilla in sitting posture
• Then on lying down on healthy side
• RESULT : Dull  Resonant
• IMMEDIATE = Hydropneumothorax
• SLOW = Pleural effusion
• ‘S’ SHAPED CURVE OF ELLIS
• PHENOMENON SEEN IN : Moderate sized pleural effusion
• LEVEL OF DULLNESS
• Highest in axilla
• Lowest in spine
• Assuming letter ‘S’
• 2 SCHOOL OF THOUGHT
• Capillary suction btw 2 layers of pleura
• Drawing fluid up
• Radiological illusion
• STRAIGHT LINE DULLNESS
• Hydropneumothorax
LIMITATIONS OF PERCUSSION
• NOT able to percuss deeper than 5 cm
• ∴ NOT possible to detect lung lesion covered by layer of
• Air > 5 cm thick
• Fluid > 1 cm thick
• Lesion < 2 cm does NOT cause any change
• Free fluid < 200 ml in pleural cavity NOT detected on percussion
AUSCULTATION
(RESPIRATORY SYSTEM)
IMP OF AUSCULTATION
• Assess CHARACTER & INTENSITY of BREATH SOUNDS
• Presence/Absence of ADDED SOUNDS
• CHARACTER of VOCAL RESONANCE
• Voiuce sounds, Whispering sounds
• Miscellaneous sounds

AUSCULTATORY AREA

ANT Above clavicle – 6th Rib


AXILLA Upto 8th rib
POST Above spine of scapula – 11th Rib
GENERAL PRINCIPLES OF AUSCULTATION
• Bell preferred over Diaphragm
• As most norm lung sounds are low pitched

• BUT Diaphragm used


• To avoid practical difficulty & time consumption
• Ask pt to breathe w mouth open
• To prevent sound production from partially closed nose
• Avoid
• Auscultation within 2-3 cm from midline
• In upper part of chest
• As these areasnormally have bronchial character
• IF CHEST HAIRY
• Moisten chest wall w H2O
• Apply chest piece tightly
• To avoid sounds by friction w hair
TECHNIQUE OF AUSCULTATION (NOT SO IMP)
• MAP OUT EXTENT OF ABNORM SOUND
• Norm to Abnorm zone
• Note area at which character changes
• CASE OF PLEURAL PAIN
• BETTER TO
• Avoid frequent deep breathing
• Test vocal resonance
• AUSCULTATION AFTER COUGHING
• Differentiate Coarse crepitation & Low pitched rhonchi from Pleural rub
• Coughing alters character of Crackles & Rhonchi

BREATH SOUNDS
• PRODUCED BY
• Vibrations of vocal cords
• Due to turbulent flow of air
• TYPES
• Vesicular
• Bronchial
• Tubular
• Cavernous
• Amphoric
BREATH SOUNDS VESICULAR BRONCHIAL
PRODUCED BY • Attenuating & Filtering effect of lung • Passage of air through trachea & large
parenchyma bronchi
AMPLITUDE Loud
CHR/NATURE Rustling Aspirate/Guttural
PITCH Low High
DURATION • INSPIRATORY : EXPIRATORY PHASE • Inspiration shortened
• = 3:1 • Expiration prolonged
• Equal (sometimes)
PAUSE BETWEEN NO YES
END OF INSPIRATION &
BEGINNING OF EXPIRATION
COND ↓ • Airless lung
• BA (i.e. Silent chest) • Consolidated lung
• Collapsed lung w Occluded bronchus • Diseased lung
• Emphysema
• Pleural effusion (small)
• Pleural thickening
• Tumour
BREATH SOUNDS TUBULAR CAVERNOUS AMPHORIC
CHR/NATURE - - Metallic
PITCH High Low Low
COND • Pneumonic consolidation • Thick-walled cavity • Bronchopleural fistula
• Collapsed lobe/lung • Large Smooth-walled
• When large draining Superficial cavity
bronchus patent
• Above level of pleural
effusion
ABSENT BREATH SOUNDS
• Agenesis of lung

• Fatal asthma (i.e. Silent chest)


• Collapsed lobe/lung
• When bronchus occluded
• Pleural effusion (massive)
• Pleural thickening (fibrothorax)
• Pneumothorax

• Pneumonectomy