7Inspection Chest wall movement: a. Expansion b. Symmetry of movement c. Paradoxical movement:Phrenic nerve paralysisFlail chest
8Inspection Breathing: Respiratory rate: Tachypnoea is a respiratory rate > 16/min and is caused by increased ventilatory drive as in fever, asthma and COPD, or reduced ventilatory capacity as in pneumonia, pulmonary oedema and interstitial lung disease.A slow respiratory rate can occur in association with opioid toxicity, hypothyroidism, raised intracranial pressure, hypothalamic lesions, and hypercapnia.
9Inspection Breathing: Respiratory depth Respiratory Rhythm Type of respiration:NormalKussamul: Hyperventilation with deep, sighing respirations (Küssmaul respiration) is a response to the reduced arterial pH in metabolic acidosis. This can occur in acute renal failure, lactic acidosis, diabetic ketoacidosis and in salicylate and methanol poisoning. The patients appear to have 'air hunger'.
10Inspection Breathing: Cheyne stroke: Cheyne-Stokes breathing, or periodic respiration, is characterized by a period of increasing rate and depth of breathing followed by diminishing respiratory effort and rate, usually ending in a period of apnoea or hypopnoea. The cycle then repeats. It is seen most frequently in stroke involving the brain stem, and in severe cardiac failure. However, it may be normal during sleep in the elderly.Use of accessory muscles: These include the sternocleidomastoids, platysma and pectoral muscles. Use of accessory muscles is characteristic of patients with COPD who have hyperinflated lungs.
11Inspection Neck region: Position of Trachea Supraclavicular fossae Causes of tracheal deviationTowards the side of the lung lesionUpper lobe or lung collapseUpper lobe fibrosisPneumonectomyAway from the side of the lung lesionTension pneumothoraxMassive pleural effusionSupraclavicular fossaeVisible pulsation, JVPLymph nodes
12Palpation Tenderness Temperature Position of Trachea: Chest Expansion: Tactile Vocal Fremitus:Apex beat localization:
13PalpationPosition of Trachea: Use one or two fingers in supra sternal notch !
14Palpation Chest Expansion: Both sides of the thorax should expand equally during tidal and maximal inspiration.Reduced expansion on one side indicates abnormality on that side, e.g. pleural effusion, lung or lobar collapse, pneumothorax and unilateral fibrosis.Bilateral reduction in chest wall movement is common in advanced COPD and diffuse pulmonary fibrosis
15Palpation Tactile Vocal Fremitus: Tactile vocal fremitus is the transmission of voice sounds from central airways to the chest wall. It is increased by solid lung, provided the airways supplying that part of the lung are patent.It is important to decide whether areas found to be dull to percussion show increased tactile vocal fremitus (suggesting consolidation or fibrosis) or reduced tactile vocal fremitus (suggesting fluid or collapse)During assessment of tactile vocal fremitus, it is conventional to ask the patient to say 'ninety -nine'. In other languages, other numbers or phrases are used. (The intention is to produce a nasal 'oi' sound).
16Palpation Apex beat localization: Deviation of the cardiac apex beat indicates shift of the lower mediastinum.Displacement of the cardiac impulse without deviation of the trachea is usually due to left ventricular enlargement but can also occur in scoliosis, kyphoscoliosis, or severe pectus excavatum.The cardiac apex beat may be difficult to localize in obesity, pericardial effusion, poor left ventricular function or patients with lung hyperinflation as in COPD.
17PercussionIdeal sites for percussion are as shown below
18Percussion Type Condition The sounds heard in different condition are as mentioned:TypeConditionResonantNormal lungHyperresonantPneumothoraxDullPulmonary consolidationPulmonary collapseSevere pulmonary fibrosis'Stony dull'Pleural effusion
19AuscultationThe stethoscope was invented by a French physician, Laennec, in 1819.Auscultate both sides alternately, comparing findings over a large number of equivalent positions to ensure that localized abnormalities are not missed.
20Auscultation Respiratory (normal) sounds Vesicular sounds Bronchial soundsVesicular soundsLower pitched, rustlingSofter relativelyInspiration longer & Expiration shorterNo Gap between Insp & Exp soundsNormally heard in lung parenchymal region (peripheral thorax)Bronchial soundsHigher pitched, hollow or blowing qualityLouder relativelyInspiration & Expiration equalGap present between Insp & Exp soundsNormally heard only along tracheobronchial tree (central thorax)
21Auscultation Adventitious(Added) sounds: Wheezes / Rhonchi Musical sounds produced by air passing through narrowed airways. e.g. asthma.Crackles (Crepititions)Non-musical sounds mainly heard during inspiration caused by:Reopening of occluded small airways. e.g. fibrosing alveolitis and pulmonary edemaAir bubbling through secretions.e.g. bronchiectasisPleural Friction rubLeathery or creaking sounds produced by movement of roughened pleural surfaces. E.g. pleurisy caused by pneumonia, pulmonary infarction. Usually associated with pleural pain.
22Auscultation vocal resonance : assess vocal resonance by asking the patient to say 'one, one, one'. In the normal lung a whispered note will not be heard but over consolidated lung, as in pneumonia, the sound is transmitted producing 'whispering pectoriloquy'.
23VARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGY Respiratory FindingsVARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGYShape of the ChestPigeon-shapedBarrel-shapedAsthma in childhoodRicketsEmphysemaSymmetry of the ChestForward BendingLateral BendingKyphosisScoliosisRespiratory rateIncreasedDecreasedFeverAcute Pulmonary InfectionsPleural PainBronchial AsthmaPulmonary EdemaRepiratory Failure
24Respiratory Findings Mode of Breathing Thoracic Abdominic Trachea Abdominal painAscitesGaseous Distension of the IntestinesLarge Ovarian CystPregnancyAnkylosing SpondylitisPleural PainIntercostal ParalysisTracheaPushedPulledPleural EffusionPneumothoraxSupramediastinal MassPulmonary ConsolidationLung CollapsePulmonary fibrosisReduced Chest ExpansionBilateralUnilateral
25Respiratory Findings Breathing Sounds Diminished Vesicular Bronchial BreathingEmphysemaPleural effusion/thickeningThick Chest wallPneumothoraxLung Collapse when large bronchi occludedPulmonary ConsolidationLarge Superficial Lung CavityPulmonary FibrosisLung Collapse when large bronchi patentVocal ResonanceIncreasedDecreasedPleural Effusion