Physical Examination in Respiratory System

nullPhysical Examination in Respiratory SystemPhysical Examination in Respiratory SystemZhao Li, M.D.Anterior imaginary lines and landmarksAnterior imaginary lines and landmarksLateral imaginary lines Lateral imaginary lines Posterior imaginary lines and landmarksPosterior imaginary lines and landmarksAnterior view of lobesAnterior view of lobesPosterior view of lobesPosterior view of lobesRight lateral view of lobesRight lateral view of lobesLeft lateral view of lobesLeft lateral view of lobesThoracic deformity Thoracic deformity Inspection Inspection Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult 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 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, 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 PercussionPercussion1. Method1. Method Mediate Pleximeter: distal inter-phalangeal joint of left middle finger Plexor: right middle finger tip Immediate Order Up to down, anterior to posterior 2. Affected factors2. Affected factorsThickness of thoracic wall Calcification of costal cartilage Hydrothorax Containing gas in alveoli Alveolar tension Alveolar elasticity 3. Classification3. ClassificationResonance Normal Hyperresonance Emphysema Tympany Cavity or pneumothorax Dullness Hydrothorax, atelectasis Flatness Massive Hydrothorax 4. Normal sound4. Normal soundLung’s sound in percussion Resonance Slight dullness in some areas (upper, right, back) due to thickness of muscles and skeletons 4. Normal sound4. Normal soundBorder 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 Down: emphysema Up: atelectasis, intraabdominal pressure goes up4. Normal sound4. Normal sound s6-8 cmDecreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia Detected impossibly: pleura adhesion, massive hydrothorax, pneumothorax, diaphragmatic paralysis 5. Abnormal sound5. Abnormal soundDullness, 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 5. Abnormal sound5. Abnormal soundDullness 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 thickness5. Abnormal sound5. Abnormal soundHyperresonance 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 Atelectasis Congestive or resolution stage of pneumonia Pulmo. edema 5. Abnormal sound5. Abnormal soundSpecial areas on percussion in moderate hydrothorax Auscultation Auscultation Order of auscultation Order of auscultation Sound of auscultationSound of auscultationNormal breath sound Abnormal breath sound Adventitious sound Vocal resonance (语音共振)1. Normal breath sound1. Normal breath soundTracheal 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 lungs2. Abnormal breath sound2. Abnormal breath soundAbnormal vesicular breath sound Abnormal bronchial breath sound Abnormal bronchovesicular breath soundAbnormal vesicular breath sound(1)Abnormal vesicular breath sound(1)Decreased or disappeared Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor Increased Movement of respiration Abnormal vesicular breath sound (2)Abnormal vesicular breath sound (2) Prolonged expiration Bronchitis Asthma emphysema Cogwheel breath sound TB Pneumonia Coarse breath sound Early stage of bronchitis or pneumonia Abnormal bronchial breath sound (tubular breath sound)Abnormal bronchial 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 breath soundAbnormal bronchovesicular breath soundBronchovesicular 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 rubMoist crackles 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. Characteristics of cracklesCharacteristics of cracklesAdventitious 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 coughClassification of cracklesClassification of cracklesAccording to intensity of the sound Loud moist crackles Slight moist crackles According to diameter of the airway crackles appeared Coarse: trachea, main bronchi, or cavity Bronchiectasis, pulmo. edema, TB, lung abscess, coma Medium: bronchi bronchitis, pneumonia Fine: bronchioli pneumonia Crepitus: Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time Site of cracklesSite of cracklesLocal: local lesion Pneumonia, TB, bronchiectasis Both bases Pulmo. edema, bronchopneumonia, chronic bronchitis 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 bronchioli due to airway narrow or incomplete obstruction. Causes Congestion Secretion Spasma Tumor Foreign subject Compression Characteristics of rhonchi Characteristics of rhonchi Adventitious sound High pitch Dominance in phase of expiration Variable intensity of character or site Wheezing Classification of rhonchiClassification of rhonchiSibilant (高调) Bonchioli, bronchi Sonorous (低调) Trachea, main bronchiSite of rhonchi Site of rhonchi Both fields Asthma Chronic bronchitis Acute left heart failure Local site Tumor Endobronchial TBPleural friction rubPleural friction rubCellulose exudation in pleurisy (rough pleura) Area of auscultation Anterolateral thoracic wall (maximal shifting area of lung) Friction rub disappeared if holding breath Friction rub appeared both breath and heart beat: mediastinal pleurisy Causes Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesotheliomaVocal resonanceVocal resonanceBronchophony (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 common respiratory diseasesMain symptoms and signs in common respiratory diseasesLabor pneumoniaLabor pneumoniaSymptoms Symptoms Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputumSigns (1)Signs (1)General signs Acute facial features, blushing Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lipsSigns (2)Signs (2)Congestion Inspection Decreased respiratory movement Palpation Increased vocal rChronic bronchitis with emphysemaChronic bronchitis with emphysemaSymptoms 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 asthmaSymptom Symptom Expiratory dyspnea with wheezingSigns Signs Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs Hydrothorax (pleural effusion)Hydrothorax (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 (Moderate to massive effusion)Signs (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 fluidPneumothorax Pneumothorax Symptoms Symptoms Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough Tension pneumonia Progressive dyspnea Tyckycardia Cyanosis Respiratory failureSigns 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 disappeared