1. Respiratory System PhysiologyBy
Dr. SHAHAB SHAIKH
PhD MD
Lecture : Clinical Examination of RS
••••••••••••••••••••••••••••••••••

2. The Doctor

3. Respiratory System Physiology Clinical Examination of RS
Inspection
Palpation
Percussion
Auscultation

4. Inspection Comfortable at rest . . . . ? Breathless . . . .?
Cyanosis ?
Chest wall appearance:
Chest wall movement:
Breathing:
Neck region:

5. Inspection Chest wall appearance: a. Shape b. Symmetry
Normally Ellipsoid
Barrel Chest - Hyperexpansion (A-P diameter increased) eg. COPD
b. Symmetry
c. Scars / Lesions
d. Deformity:
Pectus carinatum –sternum bulges forwards (‘pigeon chest deformity’)
Pectus excavatum –sternum caves inwards (Funnel chest deformity)

6. Inspection
Pectus Carinatum
Pectus Excavatum

7. Inspection Chest wall movement: a. Expansion b. Symmetry of movement
c. Paradoxical movement:
Phrenic nerve paralysis
Flail chest

8. Inspection 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.

9. Inspection Breathing: Respiratory depth Respiratory Rhythm
Type of respiration:
Normal
Kussamul: 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'.

10. Inspection 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.

11. Inspection Neck region: Position of Trachea Supraclavicular fossae
Causes of tracheal deviation
Towards the side of the lung lesion
Upper lobe or lung collapse
Upper lobe fibrosis
Pneumonectomy
Away from the side of the lung lesion
Tension pneumothorax
Massive pleural effusion
Supraclavicular fossae
Visible pulsation, JVP
Lymph nodes

12. Palpation Tenderness Temperature Position of Trachea: Chest Expansion:
Tactile Vocal Fremitus:
Apex beat localization:

13. Palpation
Position of Trachea: Use one or two fingers in supra sternal notch !

14. Palpation 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

15. Palpation 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).

16. Palpation 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.

17. Percussion
Ideal sites for percussion are as shown below

18. Percussion Type Condition
The sounds heard in different condition are as mentioned:
Type
Condition
Resonant
Normal lung
Hyperresonant
Pneumothorax
Dull
Pulmonary consolidation
Pulmonary collapse
Severe pulmonary fibrosis
'Stony dull'
Pleural effusion

19. Auscultation
The 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.

20. Auscultation Respiratory (normal) sounds Vesicular sounds
Bronchial sounds
Vesicular sounds
Lower pitched, rustling
Softer relatively
Inspiration longer & Expiration shorter
No Gap between Insp & Exp sounds
Normally heard in lung parenchymal region (peripheral thorax)
Bronchial sounds
Higher pitched, hollow or blowing quality
Louder relatively
Inspiration & Expiration equal
Gap present between Insp & Exp sounds
Normally heard only along tracheobronchial tree (central thorax)

21. Auscultation 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 edema
Air bubbling through secretions.
e.g. bronchiectasis
Pleural Friction rub
Leathery or creaking sounds produced by movement of roughened pleural surfaces. E.g. pleurisy caused by pneumonia, pulmonary infarction. Usually associated with pleural pain.

22. Auscultation 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'.

23. VARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGY
Respiratory Findings
VARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGY
Shape of the Chest
Pigeon-shaped
Barrel-shaped
Asthma in childhood
Rickets
Emphysema
Symmetry of the Chest
Forward Bending
Lateral Bending
Kyphosis
Scoliosis
Respiratory rate
Increased
Decreased
Fever
Acute Pulmonary Infections
Pleural Pain
Bronchial Asthma
Pulmonary Edema
Repiratory Failure

24. Respiratory Findings Mode of Breathing Thoracic Abdominic Trachea
Abdominal pain
Ascites
Gaseous Distension of the Intestines
Large Ovarian Cyst
Pregnancy
Ankylosing Spondylitis
Pleural Pain
Intercostal Paralysis
Trachea
Pushed
Pulled
Pleural Effusion
Pneumothorax
Supramediastinal Mass
Pulmonary Consolidation
Lung Collapse
Pulmonary fibrosis
Reduced Chest Expansion
Bilateral
Unilateral

25. Respiratory Findings Breathing Sounds Diminished Vesicular
Bronchial Breathing
Emphysema
Pleural effusion/thickening
Thick Chest wall
Pneumothorax
Lung Collapse when large bronchi occluded
Pulmonary Consolidation
Large Superficial Lung Cavity
Pulmonary Fibrosis
Lung Collapse when large bronchi patent
Vocal Resonance
Increased
Decreased
Pleural Effusion

26. Thank You