Respiratory examination

General aspects regarding respiratory system

1.Physique/Appearance

2.Decubitus

3.Cyanosis

4.Clubbing

5.Oedema

6.Lymph node

7.JVP-Cor pulmonale

8.Horner’s syndrome-Apical lung cancer

Systemic examination

Inspection

Shape of the chest-Normally eliptical

Movement of the chest

Visible pulsation

Engorged  vein

Scar mark , skin condition , hair distribution  

Respiratory rate

Intercostal and subcostal recession

Palpation

• Position of trachea[Idea is to check position of mediastinum]

         Remove the pillow

         By placing 2nd &4th finger at 2 sternal edges and middle finger in sternal notch

         Slight deviation to right is normal

        

• Position of apex[Idea is to check position of mediastinum]

• Vocal fremitus(Ask the pateint to say 99 when putting hand on chest)

                                    In spaces , start from neck

                                    In midclavicular line upto 6^th space

                                    In midaxillary line upto 8^th space

                                    In scapular line upto inferior angle of scapula

                                    
It can be increased (Fibrosis ,Consolidation , peripheral collapse , Suppurative pneumonia-FCPS), decreased (Pneumothorax , effusion ,emphysema ,thick pleura-PEET),or be absent

• Chest expansibility(Gasp whole chest ,with 2 thumbs approximation towards sternum and ask to take deep breath and see if movement is symmetrical/not)

                                    At neck , midth of chest ,subcostal region(Symmetry /not)

                                    Normally 2 thumbs should move 5 cm apart     

• Total lung expansion(Sitting position)

                                    Measure in inspiration and expiration and check difference

                                    Normally 3-5cm

                                    Restricted(<3cm)/severely restricted(<1cm)

                                          COPD , fibrosis , collapse , consolidation

Percussion

• Pitch and loudness of percussion note and post percussive vibration

Anteriorly ,  Supraclavicular area , clavicle(medial 3rd) , 2^nd ,4^th  6^th space(Bilaterally)

Laterally , 4^th  6^th , 8^th space(Bilaterally)

Posteriorly(Sitting) ,

·         Supraclavicular area bilaterally

·         Over trapezius bilaterally

·         Paravertebral space ,along medial border of scapula upto 10^th space where  scapular region  is over

[Note:

Resonant-Normal

Hyper resonant-Pneumothorax

Dull-Collapse , consolidation , fibrosis

Stony dull-Effusions]

Auscultation(Same area as percussion)

All  the beneath are To be done with diaphragm of stethoscope except supra and infra clavicular space which is to be done with bell

• Breath sound(Take deep breath in and out by open mouth—

            Normal-Vesicular 

            Bronchial-Trachea normally , consolidation ,fibrosis

                        Vesicular with prolonged expiration

                                 -Asthma , Bronchitis ,emphysema  ,interstitial lung disease ,pneumonia

• Added sounds(Checked during breath sounds with open mouth respiration)

                       
                Pleural rub(Pleurisy , PI)-Both ins and exp

                       
                Wheeze/Ronchi

·                                 Musical sounds produced during expiration due to  passage of air through narrow passage

·                                 Asthma , COPD ,bronchitis ,emphysema ,pneumonia

·                                 Inspiratory wheeze refers sever narrowing

                       
                Crepitation/crackles

·                                               Interrupted non musical sound during expiration                                      

·                                               Bronchiolitis , pulmonary edema , fibrosis ,bronchiectasis ;biphasic

• Vocal resonance(Ask the pt. to tell 99 during auscultation)—

                        Normal

                                    Increased(Consolidation)

                                    Decreased(Collapse ,effusion)

[Note:

During auscultation and percussion posteriorly ,ask pt to sit and put left palm on right shoulder and right palm on left shoulder to expand the Paravertebral space

Vesicular sound-

                             No gap between inspiration or expiration

                             Inspiration is longer and louder than expiration

                         

Bronchial sound-

                             There is gap between them

                             They both are equal

Vesicular with prolonged expiration-

                                                               No gap

                                                               Longer expiration

Trachea shift to opposite side(Push)

1.Massive Effusion

2.Tension pneumothorax

Trachea shift to same side(Pull)

1.Collapse

2.Fibrosis(bronchiectasis)

3.Cavitation

High pitched sounds are better heard with diaphragm e.g. chest sounds

Pleural rub-Anywhere on chest ,absent if resp stops

Pericardial rub-Over precordium ,better at lower left sternal edge ,continue even respiration stops]