THORAX AND LUNGS: ABNORMALITIES

presented by:

BANKWHOT NUHU
content

 Introduction
 Chest wall landmarks
 Trachea and lungs
 General observation/history
 Physical examination: abnormalities
 Posterior chest wall
 Anterior chest wall
 pulmonary function abnormalities
 Clinical presentation
 References
Chestwall: special landmarks

 2nd intercostal space for needle insertion for

tension pneumothorax.
 4th intercostal space for chest tube insertion.
 T4 for the lower margin of an endotracheal
tube on a chest x-ray.
 Neurovascular structures run along the
inferior margin of each rib, so needles and
tubes should be placed just at the superior rib
margins.
 T7–T8 intercostal space- landmark for
thoracentesis with needle insertion
immediately superior to the 8th rib
Trachea and lungs

 Aspiration pneumonia is more common in the right middle and lower lobe
because the right main bronchus is more vertical.
 Accumulations of pleural fluid, or pleural effusions, may be transudates,
seen in heart failure, cirrhosis, and nephrotic syndrome, or exudates,
seen in numerous conditions including pneumonia, malignancy, pulmonary
embolism, tuberculosis, and pancreatitis.
 Irritation of the parietal pleura produces pleuritic pain with deep
inspiration in viral pleurisy, pneumonia, pulmonary embolism,
pericarditis, and collagen vascular diseases.
history

 Chest pain
 Shortness of breath (dyspnea)
 Wheezing
 Cough
 Blood-streaked sputum (hemoptysis)
 Daytime sleepiness or snoring and disordered sleep
 A clenched fist over the sternum suggests angina pectoris; a finger
pointing to a tender spot on the chest wall suggests musculoskeletal pain;
a hand moving from the neck to the epigastrium suggests heartburn.
 Shortness of Breath (Dyspnea) and Wheezing
 The degree of dyspnea, combined with spirometry, is a key component of
important chronic obstructive pulmonary disease (COPD) classification systems
that guide patient management.
 Anxious patients may have episodic dyspnea during both rest and exercise and
also hyperventilation, or rapid shallow breathing.
 Wheezing occurs in partial lower airway obstruction from secretions and tissue
inflammation in asthma, or from a foreign body.
 Cough;
 Cough can signal left-sided heart failure.
 Day time sleepiness:
 Daytime sleepiness and snoring, are
hallmarks of obstructive sleep apnea,
commonly seen in patients with obesity,
posterior malocclusion of the jaw
(retrognathia), treatment-resistant
hypertension, heart failure, atrial
fibrillation, stroke, and type 2 diabetes.

Sleep apnea
syndrome
Physical Examination
 Respiratory distress signs (normal RR about 20breaths
per min):
 Tachypnea (>25breaths per min) increases the likelihood
of pneumonia and cardiac disease.
 Color
 Cyanosis in the lips, tongue, and oral mucosa signals
hypoxia. Pallor and sweating (diaphoresis) are common
in heart failure.
Central Cyanosis
 Clubbing of the nails occurs in bronchiectasis, congenital
heart disease, pulmonary fibrosis, cystic fibrosis, lung
abscess, and malignancy. Clubbing
 Breath sounds
 Audible high-pitched inspiratory whistling, or stridor, is
an ominous sign of upper airway obstruction in the
larynx or trachea that requires urgent airway evaluation.
Wheezing is either expiratory or continuous.
 Neck inspection
 Accessory muscle use signals difficulty breathing from COPD or
respiratory muscle fatigue. Normal chest AP
diameter<LP
 Lateral displacement of the trachea occurs in pneumothorax,
pleural effusion, and atelectasis.
 Chest shape
 ratio of the anteroposterior (AP) diameter to the lateral chest
diameter is usually 0.7 to 0.75 up to 0.9 and increases with aging.
 >0.9 in COPD, producing a barrel-chest appearance, although
evidence of this correlation is conflicting.

Right tracheal
displacement
Barrel
chest
 Pectus Excavatum
Pectus
(Funnel chest)
Carinatum
(Pigeon chest)
Posterior chest

 Inspection
 Asymmetric expansion occurs in large pleural effusions.
 Retraction occurs in severe asthma, COPD, or upper airway obstruction.
 Unilateral impairment or lagging suggests pleural disease from asbestosis or
silicosis; it is also seen in phrenic nerve damage or trauma.
 Chest expansion: Unilateral decrease
 Palpation or delay in chest expansion occurs in
chronic fibrosis of the underlying lung
 Intercostal tenderness can develop over
or pleura, pleural effusion, lobar
inflamed pleurae, costal cartilage
tenderness in costochondritis. pneumonia, pleural pain with
associated splinting, unilateral
 Tenderness, bruising, and bony bronchial obstruction, and paralysis of
“stepoffs” are common over a fractured
the hemidiaphragm.
rib.
 Crepitus may be palpable in overt
fractures and arthritic joints; crepitus
and chest wall edema are seen in
mediastinitis.
 skin abnormalities: Although rare, sinus
tracts suggest infection of the underlying
pleura and lung (as in tuberculosis or
actinomycosis).
 Tactile fremitus: Fremitus is decreased or absent when the
voice is higher pitched or soft or when the transmission of
vibrations from the larynx to the surface of the chest is
impeded by a thick chest wall, an obstructed bronchus,
COPD, or pleural effusion, fibrosis, air (pneumothorax), or
an infiltrating tumor.
 Asymmetric decreased fremitus raises the likelihood of
unilateral pleural effusion, pneumothorax, or neoplasm, which
decreases transmission of low-frequency sounds; asymmetric
increased fremitus occurs in unilateral pneumonia which
increases transmission through consolidated tissue.
Expected  Percussion
percussion  Dullness replaces resonance when fluid or
notes solid tissue replaces air-containing lung or
occupies the pleural space beneath your
percussing fingers.
 Generalized hyperresonance is common
over the hyperinflated lungs of COPD or
asthma. Unilateral hyperresonance
suggests a large pneumothorax or an air-
filled bulla.
 descent of the diaphragm, or diaphragmatic
excursion: An abnormally high level
suggests a pleural effusion or an elevated
hemidiaphragm from atelectasis or phrenic
nerve paralysis
 Auscultation
 most important examination technique
for assessing air flow through the Auscultation
tracheobronchial tree sequence
 Breath sounds: may be decreased
when air flow is decreased (as in
obstructive lung disease or
respiratory muscle weakness) or
when the transmission of sound is
poor (as in pleural effusion,
pneumothorax, or COPD).
 silent gap between the inspiratory and
expiratory sounds suggests bronchial
breath sounds.
 Lung sounds:
 In cold or tense patients, watch for
muscle contraction sounds—muffled,
low-pitched rumbling, or roaring
noises. Changing the patient’s
position may eliminate this noise. To
reproduce these sounds on yourself,
do a Valsalva maneuver (straining
down) as you listen to your own
chest.
 If bronchovesicular or bronchial
breath sounds are heard in
locations distant from normal Location of breath
area, suspect replacement of air- sounds
filled lung by fluidfilled or
consolidated lung tissue.
 Adventitious (added) sounds:
 Crackles can arise from
abnormalities of the lung
parenchyma (pneumonia,
interstitial lung disease,
pulmonary fibrosis, atelectasis,
heart failure) or of the airways
(bronchitis, bronchiectasis).
 Wheezes arise in the narrowed
airways of asthma, COPD, and
bronchitis.
 Many clinicians use the term
“rhonchi” to describe sounds
from secretions in large airways
that may change with coughing.
crackles

 Fine late inspiratory crackles that persist from breath to breath suggest
abnormal lung tissue.
 The crackles of heart failure are usually best heard in the posterior
inferior lung fields.
 Clearing of crackles, wheezes, or rhonchi after coughing or position
change suggests inspissated secretions, seen in bronchitis or atelectasis.

Fine crackles Coarse crackles

rhonchi

 “silent chest”
 Stridor and laryngeal sounds are loudest over the neck, whereas true
wheezes and rhonchi are faint or absent over the neck.
 Pleural rubs may be heard in pleurisy, pneumonia, and pulmonary
embolism.
Transmission of voice sounds

 Egophony (muffled long E sound): If “ee” sounds like “A” and has a nasal
bleating quality, an E-to-A change, or egophony, is present.
 Bronchophony (muffled indistinct “99” sound): Localized bronchophony
and egophony are seen in lobar consolidation from pneumonia.
 Whispered pectoriloquy (faint indistinct “99”): Louder, clearer whispered
sounds are called whispered pectoriloquy.
Anterior chest wall

 Inspection
 Deformity or asymmetry of thorax
 Retraction during inspiration: Abnormal retraction occurs in severe asthma,
COPD, or upper airway obstruction
 Local lag or impairment in respiratory movement: Lag occurs in underlying
diseases of the lung or pleura.
  Palpation
 Identification of tender areas:
Tender pectoral muscles or costal
cartilages suggest, but do not
prove, that chest pain has a
localized musculoskeletal origin.
Sequence  Assessment of bruising, sinus tracts,
for percussion or other skin changes
& auscultation
 Assessment of chest expansion.
 Assessment of tactile fremitus.
Tactile fremitus
  Percussion- ant to lat
( dullness 3rd to 5th left
Expected Percussion intercostal spaces- heart)
Notes
 Dullness represents airway
obstruction from
inflammation or secretions.
The hyperresonance of
COPD may obscure dullness
over the heart.
 dullness of right middle
lobe pneumonia typically
occurs behind the right
breast.
 Percuss for liver dullness
and gastric tympany:
hyperinflated lung of COPD
often displaces the upper
border of the liver
downward and lowers the
level of diaphragmatic
dullness posteriorly.
 Auscultation- ant to lat, breathing,
mouth open Location
 Listen to the breath sounds Of Breath Sounds
 Identify any adventitious sounds
 listen for transmitted voice sounds
Pulmonary function

 Forced expiratory time (3-5 sec):

 Patients ≥age 60 years with a forced expiratory time of ≥9 seconds are four
times more likely to have COPD.
 Fractured rib:
 An increase in the local pain (distant from your hands) suggests rib fracture
rather than just soft-tissue injury.
Clinical presentation

 Mr. Washington, a 36 year old banker presents with the following PE findings:
Thorax-symmetric, moderate kyphosis and increased AP diameter >0.9 with
decreased lung expansion.
Lungs- hyperresonant, breath sounds distant- delayed expiratory phase,
scattered expiratory wheezes.
Fremitus decreased- no bronchophony, egophony, or whispered pectoriloqy.
Diaphragm descends 2cm bilateraly.
What could possibly be wrong with him if the initial diagnosis are pneumonia,
COPD and Asthma?
Reference

 Bates’ guide to physical examination and history taking

Thank you