Respiratory System

objective
Determine common symptoms
Explain possible physical findings on
respiratory system.
History Taking
BREATHLESSNESS
COUGH
SPUTUM
HAEMOPTYSIS :-coughing of blood in
the sputum
WHEEZING
PAIN IN THE CHEST
OTHER hx
Physical Examination
General appearance
General assessment of the patient in relation to the
respiratory system includes:
Observation of the patient’s physique and form
 Listening to the voice of the patient for any
hoarseness and change of voice
 Observation of the hands for pallor, cyanosis and
clubbing
 Inspecting the lips and tongue for central cyanosis
Listening to the patient’s breathing if there are
additional sounds like wheezes, strider or grunting
Audible stridor, a high-pitched inspiratory
sound:
Sign of upper airway obstruction (in the
larynx or trachea)
Clubbing
Positioning
With the patient sitting: examine posterior thorax and lungs
The patient’s arms should be folded across the chest with hands
resting, if possible, on the opposite shoulders. This position
moves the scapulae partly out of the way and increases your
access to the lung fields
With the patient supine: examine the anterior thorax and lungs
 The supine position makes it easier to examine women because
the breasts can be gently displaced
Some prefer to examine both the back and the front of the chest
with the patient sitting
For patients unable to sit up without aid: try to get help so that
you can examine the posterior chest in the sitting position Or
roll the patient to one side and then to the other
Inspection

 Looking for signs of respiratory distress

 The respiratory rate, rhythm & depth
-Normal= 16-20 quietly and regularly
Observing for the shape of the chest
 Observing for the movement/ expansion
of the chest
Signs of respiratory distress:
 Flaring of ala-nasae
 Intercostal retraction
 Subcostal retraction
 The use of accessory muscles in the
neck, contraction of the sternomastoid
 supraclavicular retraction
The most common chest deformities are:
Kyphosis: posterior curvature of the spine
 Lordosis: anterior curvature of the spine
 Scoliosis: lateral curvature of the spine
 Gibbus: a posterior angular or wedge shaped
deformity of the spine. It is caused by fracture or spinal
tuberculosis (Pott’s disease)
 Flattening of the chest: Pulmonary fibrosis
 Barrel-shaped chest:
 Pigeon chest: seen in bronchial asthma and chronic
obstructive lung diseases.
 chest deformities can lead to asymmetry of the chest and
may significantly restrict lung movement
Chest deformities

Pectus excavutum/ funnel chest Barrel chest

 Pigeon chest/ pectus carinatum Kyphoscoliosis

Causes of asymmetrical chest expansion
are:
Pleural effusion
Pneumothorax
Extensive consolidation
Athelectasis
Pulmonary fibrosis
Palpation
Tracheal location: normally it is slightly
deviated to the right
 Identification of tender areas and checking
for abnormalities such as masses or sinus tracts
 Assessment of chest expansion (manually or
using measuring tape), normal= 5-8cm
Assessment of tactile fremitus: Ask the patient
to repeat the word ’ninety–nine’ or the Amharic
word “Arba-Arat” and compare both sides of the
chest symmetrically
Lateral displacement of the trachea:
pneumothorax,
pleural effusion,
atelectasis

The AP diameter may increase in COPD

Assessment of chest expansion
Manually:
Causes of unilateral decrease or delay in
chest expansion include:
chronic fibrotic disease of the lung
Pleural effusion
lobar pneumonia
Pleural pain with associated splinting, and
unilateral bronchial obstruction
Sites for feeling fremitus
..
Fremitus is decreased or absent:
When the voice is soft
When transmission of vibrations from the larynx
to the surface of the chest is impeded
The cause can be:
 obstructed bronchus,
 pleural effusion,
 pulmonary fibrosis,
 pneumothorax or
 very thick chest wall
Fremitus is increased when the
transmission of sound is increased, as
through the consolidated lung of lobar
pneumonia.
Percussion
It helps to determine whether the underlying
tissues are air filled, fluid filled or solid
 it is usually sufficient to percuss three or
four areas anteriorly, three or four areas on
the back, and two in the axillae.
 The findings on both sides of the chest
should be compared symmetrically
Normally, resonant ( low pitch and clear in
character)
Sites of percussion & auscultation
Percussion
It penetrates only about 5 cm to 7 cm into
the chest
So will not help you to detect deep-seated
lesions
Ina woman, to enhance percussion,
gently displace the breast with your left
hand while percussing with the right
Causes of dullness to percussion are
 Tumors
 Lobar pneumonia
 Hydrothorax
 Hemothorax
 Empyema
 Fibrosis
 Athelectasis
 Thick chest wall

Causes of hyper resonance are:

Bilateral causes:
 Emphysema
 Bronchial asthma
Unilateral causes:
 Pneumothorax
 Large air filled bulla in the lungs
Diaphragmatic excursion
determining the distance between the
level of dullness on full expiration and the
level of dullness on full inspiration,
normally about 5 cm or 6 cm.
Diaphragmatic excursion
An abnormally high level suggests:
pleural effusion, or a
 high diaphragm as in atelectasis or
diaphragmatic paralysis
Auscultation
Listening to the breathing sounds, added
sounds, whispered voice/whispered as
they are transmitted through the chest
wall
Listen to the breath sounds:
use diaphragm of a stethoscope
instruct the patient to breathe deeply through
an open mouth
Sounds from bedclothes, paper gowns, and the
chest itself can generate confusion in
auscultation
Hair on the chest may cause crackling sounds
Either press harder or wet the hair
Breath sounds:
Breath sounds have both intensity and quality
 The intensity (loudness): normal, reduced or
increased
Quality: vesicular, bronchial, bronchovesicular
Added sounds:
pleural friction rub, wheeze, crackles/
creaptation, rhonchi
Vesicular:
 are soft and low pitched sounds
 heard through out inspiration, continue
without pause in to expiration, and then
fade away about one third of the way
through expiration
are the normal breath sounds
Bronchial: BBS
 louder and higher in pitch
 There is a short silent period between the
inspiratory and expiratory sounds, and the
expiratory sound lasts longer than the
inspiratory one
 heard over an area of consolidated lung in
cases of pneumonia, collapse, or fibrosis,
sound resembles that obtained by listening over
the trachea, although the noise there is louder
Added sounds
Crackles
 areshort, explosive sounds often
described as bubbling or clicking
Crackles may be due to abnormalities:
Pneumonia
Fibrosis
Early congestive heart failure
Bronchitis
Bronchiectasis
Wheezes suggest narrowed airways, as in
Asthma
COPD
Bronchitis
Foreign body aspiration
Viral pneumonia/ bronchiolitis

Rhonchi suggest secretions in large airways

Transmitted voice sound
Increased transmission of voice sounds
suggests that air-filled lung has become airless
Louder, clearer voice sounds are called
bronchophony
When “ee” is heard as “ay,” an E-to-A change
(egophony) is present, as in lobar
consolidation
Louder, clearer whispered sounds are called
whispered pectoriloquy
Pleural friction rub
pleural rub:
is characteristic of pleural inflammation
usually associated with pleuritic pain
has a creaking or rubbing character
Summury
Reference
Bate’sGuide to physical examination
Hutchison’s clinical methods.22edtion
Thank you