Examination of the respiratory system

Ayman Abdo 1999

Summariesed Irom Many physical examination books as well as Irom the "JAMA
evidence based physical examination series"



For surface anatomy see Bates P.225-229
Summary :
O %he apex oI each lung rises about 2 4 cm above the inner third oI the
clavicle.
O Anteriorly : the inIerior border starts Irom about % crosses the 6
th
rib at the
midclavicular line and the 8
th
rib in the midaxillary line.
O !osteriorly : %he lower level oI the lung is at the level oI the % to % 2.
O ach lung is divided by the major ( oblique) Iissure into two lobes .
O !osteriorly : A line drown down Irom % laterally and obliquely to the 6
th
rib
in the midclavicular line.
O Anteriorly : Irom the 5
th
rib at midaxillary line to 6
th
rib at midclavicular line.
O %he right lobe oI the right lung is Iurther divided into the right upper and the
right lower lobes by the minor (horizontal) Iissure
O %he minor Iissure runs Irom the 6
th
rib at midaxillary line to the 4
th
rib
midclavicular line.

Positioning the patient :
O &ndressed to the waist
O Sitting at the side oI the bed

General :
O atch the pt Ior signs oI dyspnia at rest. Is the pt in respiratory distress ? &se
oI accessory muscles oI respiration.
O Is there any speciIic pattern oI respiration ?
Cheyne stokes pattern : hyperventilation intermittent with periods oI apnia. It is
secondary to a delay in the brain chemoreceptors to rapid changes in blood gases.
Seen mainly in brain injury , LVH and high altitude.
Kussmaul breathing : deep rapid respirations . Is secondary to stimulation oI
the respiratory centre. Seen in metabolic acidosis.
Hyperventilation :
!aradoxical respirations : abdomen sucks inwards with inspiration instead oI
normally protruding outwards.

O Count the respiratory rate (should be around 4 / min)
O Is the pt cyanosed ?
&sually seen when the amount oI deoxyhemoglobin is more than 5 g/ ml oI
blood in pt with normal Hb and more in pt with low Hb.
So iI pt Hb is less than 5 then he will not be cyanosed. It may also be evident
when the O2 saturation is less than 9 .
Central cyanosis is seen in the tongue and it means a signiIicant cyanosis as the
low O2 blood is present even in the larger arteries aIIecting areas which are
normally well perIused. %his is why it is more signiIicant and it is always a sign oI
hypoxemia.
!eripheral cyanosis may be seen in areas oI the body where blood supply is
reduced eg: lips and hands.
Causes :
Central cyanosis :
- ecreased arterial O2 saturation : G O2 , lung dis , right to leIt
shunt.
- !olycythemia
- Hb abnormailities : Meth Hb , Sulpha Hb
!eripheral cyanosis :
- All causes oI central cyanosis
- xposure to cold
- Reduced cardiac output
- Arterial oI venous obstruction
O May consider examining the pt cough and sputum
O xamine the hands Ior clubbing .
O xamine the hands Ior nicotine staining.
O vidence oI arthritis
O xamine the pulse.
O xamine Ior Ilapping tremor: dorsiIlex the wrists with outreached arms and
spread out the Iingers. May be seen in severe CO retention.
O oes the pt have Hoarseness: May be caused by laryngitis , or involvement oI
the recurrent laryngeal nerve Irom Ca or injury.
O xamine the eyes Ior evidence oI Horner`s syndrome . May be seen with
involvement oI the sympathetic chain Irom apical lung cancer.
O xamine the nose Ior : polyps ( asthma) , engorged turbinates(allergic
reaction) , and deviated septum .
O xamine the mouth Ior central cyanosis.
O xamine the %
O xamine the teeth as may be a risk Iactor Ior aspiration pneumonia.
O xamine the sinuses oI evidence oI sinusitis.
amine the chest
SPECT
O Inspection : Shape and symmetry oI the chest :
Barrel chest : increased A! diameter compared to lateral diameter. Seen in
hyperinIlation .
!igeon chest (pectus carinatum) : outwards bowing oI the sternum and costal
cartilages. May be a sign oI childhood respiratory disease. Also seen as an isolated
anomaly or Iamilial or with oonan syndrome,MarIan,.
Funnel chest ( pectus excavatum) : localized depression oI the lower end oI the
sternum. Causes similar to carinatum.
Harrison`s sulcus : linear depression oI the lower ribs just above the costal margins
at the site oI the diaphragm attachment. May be seen in severe asthma in children and
in Rickits.
Kyphosis and kyphoscoliosis .



O Inspection : lesions oI the chest wall:
Scars
Abnormal skin
Subcutanious emphysema : Seen as a diIIuse swelling oI one side oI the chest and
neck . Best Ielt than seen . seen in pneumothorax .
!rominent veins : SVC syndrome.
O Inspection : movement oI the chest wall: look or amount oI expansion and
asymmetry oI expansion

!AL!A%IO:
.
O !alpation : Chest expansion :
%humps should move at least 5 cm (degree oI expansion)
Look Ior asymmetry
O xamine the trachea : Ior location . %he trachea is shiIted towards lung Iibrosis
, collapse , and aIter pneumonectomy. It is displaced away Irom : pleural
eIIusion, pneumothorax, and ling mass. Also Ieel Ior a tracheal tug : inIerior
movement oI the examining Iinger upon inspiration . It is a sign oI over
inIlation.

O !alpation Iro the apex beat:
May be diIIicult to palpate in severe hyperinIlation
Is displaced just like lungs
O !alpation : vocal (tactile):&se one hand to compare localized areas in both
lungs . o it in Iront and the back .Causes are similar to vocal resonance
O !alpation : oI ribs iI rib Iracture is considered.

!RC&SSIO:

O !ercussion oI lung Iields:
!ercuss in similar areas both lungs between the ribs
on`t Iorget to percuss the the supraclavicular spaces
on`t Iorget to percuss in the axilla
hen percussing poseriorly move the scapula out oI the way by asking the pt to
move the elbows across the Iront oI the chest.
!ercuss Ior the Hemidiaphragm positions : with the pt sitting , percuss the lower
ends oI the lung resonance looking Ior dullness. Compare the two sides. %hey should
move about 5-7 cm each . ormally they are equal or the right side is slightly higher
by o-2 cm. II the leIt diaphragm is higher this is deIinitely abnormal and may be
caused by paralyses oI the L side , a lesion below the L side or there is a lesion at the
lower lobe oI the L lung. You may Iind that one oI the diaphragms is not moving
adequately either because oI the paralyses or a lesion eIIecting its movement.
!ercuss Ior liver dullness : may be displaced Irom hyperinIlation
!ercuss Iro the cardiac dullness.





A&SC&L%A%IO:

O Auscultation : Breath sounds :Quality oI the sounds :
ormally vesicular breath sound are heard all over the chest .&sually louder and
longer in inspiration with no gap between inspiration and expiration.
Bronchial sounds : hollow blowing sounds . Generated Irom the airways . qual
inspiration and expiration. gap between inspiration and expiration. &sually is a sign oI
consolidation but may be heard over a pleural eIIusion or a collapsed lung. It is
thought to be secondary to the Iact that the solid material inside the alveoli transmit
sound directly to the larger airways leading to airway sounds at the periphery oI the
lung instead oI the normally occurring air Iilled alveoli acoustic baIIles eIIect.
O Auscultation : breath sounds : Intensity :
O Auscultation : added sounds :
heezes : which phase ? usually starts on expiration because airways usually
dilates as the lung opens in inspiration, but iI present on inspiration it signiIies severe
obstruction .Seen in signiIicant airway narrowing. It is a poor guide to the severity oI
airway obstruction as it may be absent in severe obstruction . Localized wheezed may
indicate a localized obstruction caused by compression eg: ca.
Crackles : probably secondary to loss oI stability oI the small airways which
collapses on expiration . arly inspiratory crackles may indicate suggest disease oI the
smaller airways and indicate chronic obstructive lung disease. Late inspiratory
crackles suggests disease oI the alveoli . %hey may be Iine like seen in pulmonary
edema or harsh (Velcro) like seen in pulmonary Iibrosis.
!leural Iriction rub : usually caused by inIlamed pleura rubbing against the lung .
Indicated pleurisy.
gophony : goat voice . %he (e) appears like (a) . %his is a sensitive sign Ior
consolidation .
hispering pectoriloquy : (Chest speaking) : II pt talks while you are listening you
hear the exact words. Second most sensitive sign aIter egophony.
Bronchophony : (bronchus sounds) : Away Irom the big airways you can hear
bronchial speaking sound but without identiIying the exact words.
O Auscultation Ior Vocal resonance : with consolidation you Iind increased
vocal Iremetus .
%he heart
O Check the JV!.
O !alpate Ior a right ventricular heave or liIt.
O Listen to the pulmonary component oI the second heart sound.

Other :
O !emberton`s sign : elevation oI the arms leads to Iacial plethora , elevation oI
the JV! , and inpiratory stridor.
O Feet Ior edema
O xercise O2 sats and RR






4rrelati4n 41 respirat4ry signs with disease :

isorder isplacement Movement Percussion Sounds Extra Vocal
resonance
Consolidation one G aIIected
area
ull Bronchial Crackles
Collapse ShiIt towards GaIIected area ull Absent or
reduced
Absent
IIusion Away G aIIected
area
Stony dull Absent
over Iluid
bronchial
above
Rub ,
crackles
above
G
!neumo Away G aIIected
area
Resonant G one G
!ulm Iibrosis one G
Symmetrically
ormal ormal Late
insp
crackles
ormal


auses 41 pulm4nary 1ibr4sis :

&pper lobe : (SCHART)
O Silicosis
O Sarcoidosis
O Cole dust pneumoconiosis
O Histocytosis
O Ankylosisng spondylitis
O Radiation
O %uberculosis

ower lobe : (RASC)
O RA
O Asbestosis
O Scleroderma
O Fibrosisng alviolitis
O Meds : M% , Bleomycin, nitroIueanation , hydralazine , amiodarone)