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

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

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

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

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

6 Anterior view of lobes

7 Posterior view of lobes

8 Right lateral view of lobes

9 Left lateral view of lobes

10 Thoracic deformity Pectus excavatum Barrel chest Kyphosis

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

12 Inspection(2) 2. Respiratory rate: 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) 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 6 th, 8 th, 10 th intercostal space in midclavicular line, midaxillary line, scapular line, respectively Downward: emphysema Upward: atelectasis, intraabdominal pressure increased

22 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 Shifting range of bottom of lung 6-8 cm Along the scapular line To percuss bottom of lung, marking To ask the pat. to inspire deeply and hold 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

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

29 Auscultation

30 Order of auscultation

31 Sound of auscultation 1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance ( 语音共振 ) 5. Pleural friction rub

32 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 Bronchovesicular Bronchial Bronchovesicular

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

34 Abnormal vesicular breath sound(1) 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 2) Increased  Increased movement of respiration Exercise, fever, anemia, metabolic acidosis, compensation (single lung)

35 Abnormal vesicular breath sound (2) 3)Prolonged expiration ___ uncompleted obstruction and / or decreased alveolar elasticity  Bronchitis  Asthma  emphysema

36 Abnormal vesicular breath sound (3) 4)Cogwheel breath sound  TB  Pneumonia 5)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 1.Adventitious sound 2.Intermittent 3.Appeared in phase of inspiration or early expiration 4.Constant in site 5.Unchanged in character 6.Medium and fine crackles exist meantime 7.Less or disappeared after cough sometimes

42 Classification of moist crackles(1)  According to intensity of the sound 1. Loud moist crackles 2. Slight moist crackles

43 Classification of moist crackles(2)  According to diameter of the airway crackles appeared 1. Coarse: trachea, main bronchi, or cavity  Bronchiectasis, pulmo. edema, TB, lung abscess, coma (wheezy phlegm, 痰鸣 ) 2. Medium: bronchi  bronchitis, bronchopneumonia

44 Classification of moist crackles(3) 3. Fine: bronchioli  Bronchiolitis, Pneumonia, pulmo. congestion, pulmo. embolism 4. Velcro:  Interstitial lung disease 5. Crepitus:  Bronchiolitis, alveolitis, early pneumonia (congestion), elder subject, pat. lying in bed for long time

45 Site of crackles 1. Local: local lesion Pneumonia TB Bronchiectasis 2. Both bases Pulmo. congestion Bronchopneumonia, 3. 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 1. Adventitious sound 2. High pitch 3. Dominance in phase of expiration 4. Variable intensity, character, site or spread 5. Wheezing (appeared in main bronchi)

48 Classification of rhonchi 1. Sibilant ( 哨笛音，高调 ) Bonchioli, smaller bronchi 2. Sonorous ( 鼾音，低调 ) Trachea, main bronchi

49 Site of rhonchi 1. Both fields Asthma Chronic bronchitis Acute left heart failure (cardiac asthma) 2. 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

51 Pleural friction rub 1. Cellulose exudation in pleurisy (rough pleura) 2. Area of auscultation inferolateral thoracic wall (maximal shifting area of lung) 3. Friction rub disappeared if holding breath 4. Friction rub appeared both breath and heart beat: mediastinal pleurisy 5. Causes Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma

52 Main symptoms and signs in common respiratory diseases

53 Labor pneumonia

54 Symptoms  Chill  Continued fever: 39-40ºC  Chest pain  Tachypnea  Cough  Rusty sputum

55 Signs (1)  General signs Acute facial features, blushing ( 颜面潮红 ) Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lips

56 Signs (2)  Congestion stage Decreased movement of respiration in affected area Increased vocal fremitus Dullness Crepitus

57 Signs (3)  Consolidation stage Obviously increased vocal fremitus (resonance) Dullness or flatness  Abnormal bronchial breath sound (tubular breath sound) Pleural friction rub  Resolution Moist crackles

58 Chronic bronchitis with emphysema

59 Symptoms  Chronic productive cough  White mucous sputum or pus sputum (infection)  Usually exacerbation in winter  Morning cough  To last more than 3 months  Exertional dyspnea  Breathlessness (dyspnea)  Chest depress

60 Signs  Barrel chest  Movement of respiration  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)

61 Bronchial asthma

62 Symptom  Expiratory dyspnea with wheezing

63 Signs  Expiratory dyspnea with wheezing  Orthopnea  Cyanosis  Severe sweat  Decreased movement of respiration  Decreased vocal fremitus  Hyperresonance  Rhonchi in full fields of lungs

64 Hydrothorax (pleural effusion)

65 Symptoms  Dry cough  Chest pain Disappeared with growing of pleural effusion Reappeared with the fluid decreasing  Affected side lying  Dyspnea, orthopnea, palpitation  The symptoms of underlying disease  300ml: no obvious symptoms >500ml: breathlessness, chest depress

66 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  Decreased or disappeared vocal resonance  Pleural friction rub  Abnormal bronchial breath sound in upper area of the fluid

67 Pneumothorax

68 Symptoms  Sudden chest pain  Dyspnea  Forced sitting position  Unaffected side lying  Dry cough  Tension pneumothorax Progressive dyspnea Severe sweat Tyckycardia Tension, agitated Cyanosis Respiratory failure

69 Signs  Costal interspaces in affected side are wider  Limited movement of affected side  Decreased or disappeared vocal fremitus  Trachea and heart shift to opposite side  Tympany  Vesicular breath sound decreased or disappeared