The boundary of lung and pleura

The boundary of lung and pleura
Visceral pleura:the pleura covering the surface of the lung Parietal pleura: the pleura covering the inner surface of the chest wall,the diaphragm,and the mediastinum

On the right, the dome of the diaphragm is situated at a level approximating the fifth rib or fifth interspace at the midclavicular line.The dome of the left diaphragm is ordinarily about 1 inch lower than the right.

THORAX AND LUNGS

INSPECTION Inspection of the chest,productive of the maximum amount of information, requires the following: 1. First and foremost,a definite desire to see and to appreciate every visible abnormality 2. The patient stripped to the waist 3. Good lighting

INSPECTION 4. A thorough knowledge of topographic anatomy
5. The examiner and patient in a comfortable position throughout the examination. If either the physician or patient is uncomfortable,the examination may be hurried and consequently less thorough. It is important that the patient be absolutely straight,whether seated or supine.

INSPECTION Normal thorax
You should know that in normal subjects there is a wide variation in the size and shape of the thorax.At times it is difficult to be certain where the normal variations and definite pathologic changes begin.

INSPECTION Normal thorax
The anteroposterior diameter of the thorax in the normal adult is less than the transverse diameter.

INSPECTION what to observe
1.First: the general nutrition and musculoskeletal development 2.Next: the skin and breasts 3.vein and subcutaneous emphysema

INSPECTION 4.the anteroposterior diameter of the thorax
persons with pulmonary emphysema --barrel chest 5.the general slope of the ribs normal : 45 º degree angle patients with emphysema :the ribs are nearly horizontal ; this angle becomes abnormally wide

INSPECTION 6.retraction or bulging of interspaces
Retraction of the interspaces: obstruction of the respiratory tract Bulging of interspaces : a massive pleural effusion,tension pneumothorax

INSPECTION 7.the rate and depth of quiet breathing
in the adult at rest the normal respiratory rate is approximately 16 to 18 breaths per minute and is quite regular in depth and rhythm increase in the respiratory rate :fever

INSPECTION 8.Alterations in shape of the thorax
In the normal subject,the two sides of the chest move synchronously and expand equally Unilateral retraction of the thorax : a thickened fibrotic pleura Pigeon chest Funnel chest

INSPECTION 9.Types of respiration
(1)Dyspnea : difficulty in breathing ; participation of the accessory respiratory muscles Inspiratory dyspnea :obstruction of the trachea or major bronchi (tumor,laryngitis) Expiratory dyspnea :obstruction in the bronchioles and smaller bronchi (asthma)

(2)Bradypnea : abnormal slowing of respiration (3)Apnea : temporary cessation of breathing (4)Tachypnea : increased respiratory rate (5)Hyperpnea : an increase in the depth of respiration (6)Hyperventilation :an abnormal increase in both rate and depth of respiration (it is seen in diabetic acidosis and highly emotional states)

(7) restrained breathing :the inspiratory phase is suddenly interrupted as a result of pain associated with acute pleuritis ; The respirations are quite shallow but more rapid than normal

(8)tidal respiration :is characterized by periods of rapidly increasing rate and depth of respiration, which within a matter of a few more respiratory cycles becomes shallower and shallower until respiration ceases.This is followed by a period of apnea,which may last a few seconds to as long as 30 seconds. periodic respiration may be present in many relatively severe disease states.

(9)Sighing respiration :occurs when the normal respiratory rhythm is interrupted by a deep inspiration,which is followed by a prolonged expiration and ordinarily is accompanied by audible sighing. it is rarely associated with organic disease;instead it is almost always a manifestation of emotional tension.

(10)Ataxic breathing: is characterized by unpredictable irregularity . Breaths may be shallow or deep,and stop for short periods.

PALPATION Thoracic expansion
Variations in expansion are more readily detectable on the anterior surface where there is greater range of motion. The examiner's hands should be placed over the lower anterolateral aspect of the chest. Expansion should be tested during both quiet and deep inspiration.

PALPATION Thoracic expansion
Expansion may be limited as the result of acute pleurisy,fibrous thickening of the pleura (fibrothorax),fractured ribs,or other trauma to the chest wall.

PALPATION Fremitus Vocal fremitus :Vocal fremitus is a palpable vibration of the thoracic wall produced by phonation .

PALPATION Vocal fremitus:
The sounds that arise in the larynx are transmitted down along the air column of the tracheobronchoalveolar system into the bronchi of each lung,on through the smaller bronchi into the alveoli,setting in motion the thoracic wall that acts as a large resonator. Thus,vibrations are produced in the chest wall that can be felt by the hand of the examiner.

In eliciting vocal fremitus the patient is directed to count “one,two,three”---“one,two,three”,to repeat the words“ninety-nine”—“ninety-nine”,or to say “ e-e-e,e-e-e,e-e-e”. The patient should speak with a voice of uniform intensity throughout the examination so that the examiner can better compare the transmission of the fremitus in different areas of the chest.

The vocal fremitus is perceived by placing the palmar aspect of the fingers or ulnar aspect of the hand against the chest wall.Usually both hands are used,placing them in corresponding areas so that comparison of the two sides can be made. If only one hand is used,it should be moved from one place to the corresponding area of the other side to compare the transmission of sound.

PALPATION Normal variations of vocal fremitus.
The intensity of the vocal fremitus perceived in the normal subject is governed by the following: 1.Intensity of the voice 2.Pitch of the voice 3.Varying relations of the bronchi to the chest wall 4.Varying thickness of the thoracic wall

PALPATION In general,vocal fremitus is most prominent in the regions of the thorax where the large bronchi are the closest to the thoracic wall and tends to become less intense as one progresses farther from the major bronchi.In the normal person the fremitus is found at maximum intensity over the upper thorax both anteriorly and posteriorly.It is least intense at the bases.

PALPATION Also the intensity of the fremitus will vary with the thickness of the thoracic wall.In a thin person the vibrations will be more intense than in the normally developed or obese patient. There is considerable variation from patient to patient.

PALPATION Alternations of vocal fremitus
increased vocal fremitus ----consolidation of the lungs :lobar pneumonia Decreased fremitus ----fibrous thickening of the pleura: fluid in the pleural space or pneumothorax absent fremitus ---- major bronchus is obstructed :tumor

PALPATION pleural friction fremitus :As the result of acute pleurisy,the inflamed pleural surfaces rub against one another,producing a pleural friction rub that may be detected by the examining hand.

PALPATION pleural friction fremitus
When present,it is palpable usually in both phases of respiration. Friction rubs most commonly are felt as well as heard in the inferior anterolateral portion of the chest,the area of greatest thoracic excursion.

PALPATION Crepitation
Crepitation may be palpated when the sub cutaneous tissues contain fine beads of air. This condition is known as subcutaneous emphysema. A somewhat similar sensation can be produced by rolling a lock of hair between the thumb and fingers.

PERCUSSION There are two principal methods that may be used for percussion of the thorax, abdomen,or other structures.

PERCUSSION 1. Mediate percussion is that in which the examiner strikes the middle finger of one hand held against the thorax, thus producing a sound by setting the chest wall and underlying structures in motion. This is the method in almost universal use today.

PERCUSSION 2. Immediate percussion may be useful in demonstrating changes in percussion note.This can be done by striking the chest with the tips of all of the fingers held firmly together.

PERCUSSION Practical experience has demonstrated that useful sounds produced by percussion probably do not penetrate more than about 4 to 5cm below the surface. Also a lesion must be at least 2 or 3cm in diameter to be detectable. Thus,it is obvious that percussion will only locate rather gross abnormalities.

PERCUSSION To obtain the maximum information from percussion:
1. The distal phalanx of the pleximeter finger must be pressed firmly on the chest wall;otherwise,a clear note is not ob tained. 2. The plexor finger should strike the pleximeter finger only instantaneously and must be immediately withdrawn.

PERCUSSION Usually percussion is performed above the clavicles in the supraclavicular spaces and downward.Next,each lateral wall is examined, beginning in the axilla and working down to the coastal margin. With the pleximeter finger always parallel to the ribs--never cross them.

PERCUSSION In examining the back of the chest the patient should have his head inclined forward and the forearms crossed comfortably at the waist to move the scapulae as far laterally as possible.

PERCUSSION Examination is started at the apices, where the percussion note as well as the width of the isthmus of normal resonance over the apex is determined . Bounded medially by the neck muscles and laterally by the shoulder girdle,this band of resonance is normally about 5 cm wide.

PERCUSSION The percussion is continued downward, interspace by interspace,to the bases where the location and range of motion of each hemidiaphragm is ascertained.

PERCUSSION Analysis of percussion tones
The sound waves produced by percussion are influenced more by the character of the immediate underlying structures than by those more distant. Consequently the tone produced by percussion over the airfilled lung will be different from the tone heard over a solid structure,such as the heart or liver.This is the basis for the scientific application of percussion.

PERCUSSION Percussion sounds
1. Resonance: the sounds heard normally over lungs 2. Hyperresonance: The hyperresonant note in the adult is commonly the result of emphysema.

3. Tympany : It never occurs in the normal chest,except below the dome of the left hemidiaphragm,where the underlying stomach and bowel will produce tympany.

4.Dullness: Dullness tends to occur when there is solid or liquid medium present in the underlying lung in proportion to the amount of air in the lung tissue. Thus,dullness will be found when there is consolidation of lung,such as occurs in pneumonia,or when there is a moderate amount of fluid in the pleural space with some underlying air-containing lung.

5. Flatness is the term used to describe the percussion note when resonance is absent. Flatness will be present when there is a very large fluid mass,such as in an extensive pleura1 effusion with little underlying air-bearing lung to influence the sound.

Over the apices,where there are large amounts of muscle and bone with relatively little underlying resonant lung,the note is less resonant than over the bases,where there is a relatively greater amount of lung with less thoracic wall and muscle.

The development of the pectoral muscles,the heavy muscles of the back,the breasts,and the scapulae,all tend to make the percussion note less resonant (duller).

It should be noted that below the dome of the right diaphragm there is flatness because of the presence of the liver.on the left there is a relatively tympanic note that results from the presence of the partially air-filled stomach and bowel under the hemidiaphragm.

The change from resonance to flatness on the right and from resonance to tympany on the left is not immediate;instead ,there is a zone of transition.

Dullness from the liver is usually noted at approximately the fifth interspace in the midclavicular line,and this dullness soon gives way to flatness as that part of the liver not covered by the lung is reached.

Also the change from pulmonary resonance to tympany over the left lower chest at about the sixth rib in the midclavicular line has the same general tendency to transition not an abrupt change .

There is also dullness to the left of the sternum,caused by the underlying heart, another solid organ in the left fifth interspace. This dullness normally extends to a point 1 or 2cm medial to the midclavicular line.

PERCUSSION Effect of position on percussion sound
Occasionally the patient is too ill to sit up to permit percussion of the posterolateral aspects of the chest.So the posterior and posterolateral thoracic wall must be examined with the patient rolled on his side.This is much less satisfactory than the upright position.

PERCUSSION The lateral recumbent position causes the following changes:

PERCUSSION 1.Some curvature of the spine results,with a widening of the intercostal spaces in that portion of the thoracic wall that is against the bed and a narrowing of the interspaces on the upper side;this curvature can be counteracted to some degree if the pillow is removed and the head is allowed to the bed.

PERCUSSION 2. Disproportionate elevation of the hemidiaphragm of the down side results from the pressure of the abdominal viscera. 3. The surface of the bed affects the percussion note by acting as a damper for the sounds.

PERCUSSION As a result of these three factors ,the following changes are observed: (1)there is an area of relative dullness along the chest next to the bed.

PERCUSSION (2)above this area and at the base of the lung there is a roughly triangular area of dullness with the base toward the bed and the apex approaching the spine.

PERCUSSION (3)on the upper side there may be some relative dullness at approximately the tip of the scapula,which is caused by changes in the lung as a result of the crowding of the ribs.

PERCUSSION Diaphragmatic excursion
First,the patient is instructed to take a deep inspiration and hold it. Second, the lower margin of resonance (which represents the level of the diaphragm)is determined by percussion from the normal lung,moving downward until a definite change in tonal quality is heard.

Third,the patient is instructed to exhale as far as possible and to hold his breath, and the percussion is repeated. The distance between these levels indicates the range of motion of the diaphragm .

The normal diaphragmatic excursion is about 6 to 8 cm. It is decreased in patients with pleurisy and severe emphysema.

PERCUSSION The diaphragm is unusually high in any condition that causes an increase in intra-abdominal pressure, such as ascites or pregnancy and lower than normal in pulmonary emphysema. In the recumbent patient the level of the diaphragm is approximately one interspace higher than in the upright position.

AUSCULTATION The patient should be instructed to breathe a little deeper than usual with his mouth open. Breathing through the open mouth minimizes the sounds produced in the nose and throat. Corresponding areas of each side are auscultated as the examiner goes from top to bottom, just as in percussion.

Breath sounds--normal
AUSCULTATION Breath sounds--normal

Vesicular The vesicular breath sound is believed to be the result of movement of air in the bronchioles and alveoli. Variously described as sighing or a gentle rustling,vesicular breathing is a soft, relatively low-pitched sound. The normal vesicular respiration is longer in the inspiratory than in the expiratory phase by a ratio of approximately 5:2.

Vesicular It should be emphasized that expiration as heard in vesicular breathing is not actually shorter than inspiration --only that much of expiration is not audible. Inspiration is higher in pitch and louder than expiration.In fact,expiration occasionally may be inaudible. Vesicular breath sounds heard from normally over most of the lungs.

Bronchovesicular In certain areas where the trachea and major bronchi are in proximity to the chest wall,there is heard a mixture of both tracheobronchial and vesicular elements that is termed bronchovesicular breath sound.

Bronchovesicular This type of breath sound is heard normally on each side of the sternum in the first and second interspaces,between the scapulae, and over the apices anteriorly and posteriorly,but are more prominent on the right than on the left. When heard in other locations, brochovesicular breathing is abnormal and indicated of some diseases.

Bronchovesicular In bronchovesicular breathing the inspiratory phase resembles that of normal vesicular breathing,and the expiratory phase resembles that of normal bronchial breathing. A very brief pause may be noted between inspiration and expiration. In essence,the expiratory and inspiratory phases are very similar as to duration, pitch,intensity,and quality.

Vesicular and bronchovesicular are the two types of breath sounds heard normally over the lungs.

Breath sounds--abnormal
AUSCULTATION Breath sounds--abnormal

Bronchial breathing Bronchial breath sounds are in general higher in pitch than vesicular or bronchovesicular sounds. Expiration usually surpasses inspiration in length.

Bronchial breathing Bronchial breathing is not normally heard over the lungs. Therefore,its presence over the lungs always indicates disease. It occurs only with pulmonary consolidation, in other words,an increased conducting mechanism.

Bronchovesicular breathing
Bronchovesicular breathing is abnormal when heard in any area of the lungs that normally have vesicular breath sounds. An admixture of consolidated and aerated lung produces a mixture of bronchial and vesicular breathing--bronchovesicular breath sounds.

Elongated expiratory breath sound
Occurs because of partial obstruction,spasm of the lower respiratory tract, happening in bronchitis,bronchial asthma etc. Because of lowering elasticity of pulmonary tissue,happening in COPD etc.

Hoarse breath sound Due to smoothlessness produced by mild bronchial membranous edema or inflammation. Heard in the early stages of bronchial or lung inflammations.

Decreased or absent breath sounds
Breath sounds may be decreased in intensity without change in fundamental type as the result of several conditions.In some instances the breath sounds may be entirely absent.

l.One of the most common causes is fluid in the pleural space.Here the diminution in breath sounds is the result of the interposed liquid medium as well as a definite decrease in ventilation of the underlying lung. 2.In the same manner ,air in the pleural space(pneumothorax)causes a diminution in the breath sounds.

3. If there is thickened pleura caused by fibrosis -which may follow effusion,hemothorax, and empyema-or by actual tumor involvement of the pleura,decrease in breath sounds is noted. Whether fluid,air,or solid in the pleural space,all interfere with the conduction of breath sounds so that they are decreased or even absent .

4. Breath sounds are commonly decreased in emphysema because of the decreased air velocity and sound conduction. 5. Breath sounds are markedly diminished or absent in complete bronchial obstruction. 6.If there is definite decrease in expansion, such as that commonly noted in painful pleurisy with its attendant shallow breathing,the breath sounds are diminished because of the decreased ventilation.

AUSCULTATION voice sounds--normal

Vocal resonance Vocal resonance is produced in the same fashion as vocal fremitus.The spoken voice as heard over the normal lung is termed vocal resonance. Vocal resonance varies in exactly the same fashion as does vocal fremitus.It is heard loudest near the trachea and major bronchi and is less intense at the bases.

Voice sounds--abnormal
AUSCULTATION Voice sounds--abnormal

Bronchophony Bronchophony indicates vocal resonance that is increased both in intensity and clarity. It is usually associated with increased vocal fremitus ,dullness to percussion,and bronchial breathing,and as a rule indicates the presence of pulmonary consolidation.

Whispered pectoriloquy
To be of practical significance the sounds must be actually whispered;softly spoken words that require the use of the vocal cords are not suitable. In the normal subject the whispered voice is heard only faintly and indistinctly throughout the chest except anteriorly and posterior1y in the regions overlying the trachea and primary bronchi.At the bases the whispered voice may be entirely inaudible.

Pectoriloquy Although pectoriloquy is only a form of exaggerated bronchophony, at times it is more easily detected than bronchophony. Pectoriloquy is never normal,and its presence always indicates consolidation of the lung.

Egophony Egophony is a modified form of bronchophony in which there is not only an increase in intensity of the spoken voice but its character is altered so that there is a definite nasal or "bleating" quality. It is occasionally heard over an area of consolidation,over the upper portion of a pleural effusion,or where there is a small amount of fluid in association with pneumonic consolidation. It is most readily elicited by having the patient say"e-e - e."If egophony is present,the spoken "eeee"will sound as though the patient is saying "aaaa."

Decreased vocal resonance
Vocal resonance is decreased under the same circumstances that the vocal fremitus and the breath sounds are decreased or absent-where there is interference in the conduction of vibrations produced in the thorax,such as is found with pleural thickening , pleural fluid , pneumothorax, adiposity,or complete bronchial obstruction.

Decreased vocal resonance
It should be noted that,although the vocal resonance and vocal fremitus are usually diminished over a pleural effusion, occasionally they may actually be increased at the upper level of the fluid as the result of compression of the lung or if there is pneumonic consolidation of the underlying lobe.

AUSCULTATION Adventitious sounds

The most common adventitious sounds are the various types of rales ,rhonchi and the pleural friction rub

Rales They result from the passage of air through secretions in the respiratory tract and from reinflation of the alveoli and bronchioles, the walls of which have become adherent as the result of moisture.Rales,therefore,are produced by air flow plus abnormal moisture.

Rales According to the size of the air chamber involved (trachea,bronchi,bronchioles,and alveoli)and the character of the exudate,rales vary in their size,intensity,distribution, and persistence. Rales are most often heard in the terminal phase of inspiration and are more pronounced when the patient is instructed to breathe deeply. Rales are very similar to the sound heard over a recently opened carbonated drink.

Rales Rales may be divided roughly into three kinds: fine, medium, and coarse.

Fine Rales Fine rales have a fine,crackling quality. They most commonly occur at the end of inspiration and are not cleared by coughing . they are the result of moisture in the alveoli.

Fine fales Fine rales indicate inflammation or congestion involving the alveoli and bronchioles. Consequently they may be heard in pneumonia, pulmonary congestion, and many other diseases.

Medium rales Medium rales represent a gradation between coarse and fine rales. They may be simulated by rolling a dry cigar between the fingers. They tend to be the result of the passage of air through mucus in the bronchioles and small bronchi or the separation of the walls of these structures that have become adherent because of exudate. Medium and coarse rales tend to occur earlier in respiration than do fine rales.

Coarse rales Coarse rales have their origin in the trachea, bronchi and some of the smaller bronchi. They are produced by the passage of air through exudate.Often they will clear,at least in part,as the result of a vigorous cough. They may be heard during the resolution of an acute pneumonia,at which time there is the production of relatively large amounts of thick exudate. In the moribund patient who has a definite depression of his cough reflex,there is often an accumulation of thick secretions,producing very coarse rales.

Rhonchi Rhonchi differ from rales in that the former are continuous sounds,similar to the sound produced by playing a violin. Rhonchi are continuous sounds produced by the passage of air through the trachea, bronchi,and bronchioles that have been narrowed. As long as air passes the obstruction,the sound will be produced.

Rhonchi Rhonchi are more prominent during expiration than inspiration, although they are frequently audible during inspiration. Based on the pitch, rhonchi are classified as sibilant and sonorous .

Sibilant rhonchi Sibilant rhonchi are high pitched, wheezing or musical in character.The wheezing quality often can be emphasized by forced expiration. They have their origin in bronchioles and smaller bronchi.

Sonorous rhonchi Sonorous rhonchi are low pitched and often moaning or snoring in character. They are produced by obstruction in the larger bronchi or trachea.

Rhonchi tend to vary greatly in intensity and character from time to time. In some instances they can be cleared,or partially so,by coughing.

Rhonchi are produced as air enters the area of obstruction and again as it leaves.
The underlying obstruction or narrowing may be the result of variety of causes:extrinsic compression as by enlarged lymph nodes or mediastinal tumor or by intrinsic narrowing as in bronchogenic carcinoma,exudate,mucosal inflammation or edema,and bronchiolar spasm(asthma). In each instance there are narrowing and irregularity in the tracheobronchial tree,with resultant turbulence of the air producing the sound.

pleural friction rub Normally the visceral and parietal surfaces of the pleura glide noiselessly over one another during respiration. However,when these surfaces become inflamed,as the result of pleurisy, pulmonary infarct, or underlying pneumonia,the rubbing of the roughened surfaces during respiration produces a very characteristic sound that is known as the pleural friction rub.

pleural friction rub The characteristics of a friction rub can be imitated by pressing the palm of one hand over the ear and then lightly and slowly rubbing the back of the hand with the fingers of the other hand. It is usually heard during both phases of respiration.If audible in only one phase,it is most commonly heard during inspiration,particularly at the end. At times friction rubs are not heard during quiet breathing but are only audible when the patient takes a deeper breath.

pleural friction rub The most common site for a friction rub to be heard is the lower anterolateral chest wall, the area of greatest thoracic mobility. It does not disappear with coughing as coarse rales will often do,and that cough is usually attended by discomfort. Furthermore,an increase in the intensity of the friction rub may be noted with arm pressure of the stethoscope over the thoracic wall.

MAJOR ALTERATIONS OF THE LUNGS

Pleural effusion

A collection of fluid in the pleural space is called pleural effusion
A collection of fluid in the pleural space is called pleural effusion. Pleural effusion is a sign of disease and not a diagnosis in itself. The physical sign of a pleural effusion are the same whether it is serious, hemorrhagic, or purulent in character.

Inspection The patient usually lies on the affected side, thus allowing free expansion of the normal lung. If the amount of the effusion is large, the patient may show marked dyspnea. The movements of the chest during respiration are diminished on the affected side.

Inspection In large effusions the affected side appears much fuller than the normal one, and the intercostal spaces may actually bulge. When the effusion is on the right side, the cardiac impulse may be displaced beyond the left midclavicular line.

Palpation Palpation first confirms the observation made on inspection; decreased mobility with bulging of the intercostal spaces on the affected side and displacement of the cardiac impulse. The trachea is deviated away from the diseased side. The vocal fremitus is absent or markedly diminished over the effusion.

Percussion In small effusions and in early stages of any pleural effusion, the percussion note may be unchanged. As more fluid accumulates, the percussion note becomes less and less resonant, and finally becomes dull to flat.

Percussion When the effusion is on the right side, the dullness extends into and cannot be set apart from the liver dullness. A right side plural effusion displaces the heart to the left, and the cardiac dullness toward the left axilla. In a left sided plural effusion the dullness extends into that of the cardiac dullness, and percussion of the left cardiac border may be impossible.

Auscultation Early in the disease a friction rub may be heard, which, however, soon disappears. The breath sounds are diminished or absent over the area of the effusion. Bronchovesicular breath sounds are often heard at the upper limit of the fluid, because of the compressed underlying lung.

Auscultation The vocal resonance is diminished or absent over effusion. The whispered voice may be intensified ----bronchophony, especially just above the level of the effusion.

Pneumonia

Any lung infection that involves the alveoli and causes then to fill with exudate or inflammatory secretion is called “pneumonia”. Pneumonias usually sudden, often coughing is usually present. It may be severe and associated with sharp pain in the affected side. The sputum at first is mucoid, but later becomes bright red and then rusty brown.

The signs of consolidation is commonly found over lobar pneumonia.

Inspection Dyspnea is almost invariably present and the respiratory rate is increases. In severe cases, cyanosis of the tip of the nose, ears and fingertips is commonly present, and movements are decreased on the affected side and increased on the normal side .

Palpation The diminished respiratory movements on the affected side are often better felt then seen. A pleural friction fremitus may be felt because of a coexisting acute pleuritis. The vocal fremitus is greatly increased over the pneumonic area.

Percussion In a lobar pneumonia the percussion note is dull or flat over the affected area.

Auscultation In the early stages of lobar pneumonia, the breath sounds may be diminished or suppressed. Fine crepitant rales may be heard. With the development of consolidation, the crepitant rales disappears, the breath sounds become tubular . The vocal resonance is increased and the voice sounds may have a nasal tone ----the egophony.

Auscultation During resolution ,the cyanosis and tachypnea disappear, the areas of auscultation numerous small and large moist rales are heard in increasing numbers, while the harsh tubular breathing gradually disappears and normal vesicular breathing reappears.

Pulmonary emphysema

By definition “emphysema” refers to the presence of an abnormally large amount of air within portions of the lung distal to the terminal bronchioles. The history is often progressive dyspnea, starting after cough, sputum for many years.

Inspection A “barrel chest deformity” is frequently present.
The chest is on an inspiratory position, with the ribs horizontal. The apex beat of the heart is not visible.

Palpation The trachea is in the midline position.
The fremitus is diminished over both side of the chest. The chest movement is restricted but equal bilaterally. The apex beat cannot be felt.

Percussion there is hyperresonance throughout both sides of the chest.
the area of cardiac dullness is diminished. The upper limit of liver dullness is lowered. After deep inspiration followed by forced expiration, percussion over the bases of the lung in the back shows little change in the lower limits of lung resonance.

Auscultation On auscultation the breath sounds are vesicular and generally diminished in intensity or almost inaudible. Expiration is commonly prolonged. Rhonchi are normally widespread, but may be most marked at the bases of the lung.

Pulmonary atelectasis

Atelectasis occurs when an area of lung tissue is not ventilated
Atelectasis occurs when an area of lung tissue is not ventilated. The signs and symptoms that follow depend upon the amount of lung tissue involved and vary from an asymptomatic shadow on an X-ray to acute respiratory distress. When a large amount of lung is involved, there are signs of respiratory distress, and the physical findings are as following:

Inspection The chest on the affected side looks flat, the intercostal spaces narrowed and depressed. The respiratory movements are markedly diminished, while there is increased expansion over the normal side.

Palpation The fremitus is usually decreased or absent over the affected side. The trachea is deviated to the affected side.

Percussion Percussion shows that the heart is displaced toward the affected side. The percussion note over the affected lung is usually dull.

Auscultation The breath sounds are usually absent over the affected area. Rales may not be present.

Pneumothorax

An accumulation of air in the pleural space is called pneumothorax
An accumulation of air in the pleural space is called pneumothorax. In acute spontaneous pneumothorax the patient show sudden dyspnea, cyanosis and chest pain. If the pneumothorax is small,the alterations may be minor or even absent.

Inspection Unilateral diminishing of movement may be present in variable degree. The cardiac impulse is displaced to the left in a right pneumothorax, and to the right in a left pneumothorax.

Palpation Tracheal deviation away from the affected side can be find, if the pneumothorax is large. The vocal fremitus is diminished or abolished over the affected side.

Percussion The percussion note over the affected side is usually tympanic.

Auscultation The vocal resonance is usually diminished.
The breath sound are markedly diminished on the affected side and exaggerated on the normal side.

The boundary of lung and pleura

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