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respiratory system
Ding Xuhong
Department of Pulmonary Medicine
Renmin Hospital, Wuhan University
Common symptoms
Dyspnea
Cough and sputum
Hemoptysis
Chest pain
Dyspnea
Breathlessness inappropriate to
the level of physical exertion, or
even occurring at rest
• Severity
Is the dyspnea related only to
exertion?
How far can the patient walk at
normal pace on the level?
• Variability
Are there good days or bad days?
(seasonal variation)
Are there any times of day or night
that are usually worse than others?
Cough
• Acute or chronic
How long has the cough been
present?
• Time relationship
Is the cough worse at any time of
day or night?
• Precipitating factors
Is the cough aggravated by
anything, for example dust, pollen or
cold air?
• Productive or nonproductive
Is sputum produced?
• Type and quantity of sputum
What does it look like?
How much is produced?
Hemoptysis
Coughing of blood in the sputum
Is there any blood in the sputum?
Is it fresh or altered blood?
How often has it been seen and for
how long?
Difficulty in justify the origin of
blood: gums, nose, stomach
Chest pain
• caused by lung diseases usually
arises from the pleura: pleuritic pain
• caused by local invasion of the
chest wall by a lung tumor: constant,
unrelated to breathing
Pleuritic pain
sharp, stabbing, made worse by
deep breathing or coughing
• inflammation of the pleura
• spontaneous pneumothorax
• pulmonary infarction
The Examination of The
Respiratory System
• Relevant anatomy
• Examination of the chest
• Putting it together
Relevant anatomy
Sternal angle (Louis angle)
• The junction of the manubrium and
body of the sternum
• The location of other important
structures at the same level: (1) the
second rib; (2) the disc between the
fourth and fifth thoracic vertebrae;
(3) the bifurcation of the trachea; (4)
the upper level of the atria of the
heart
Major interlobar fissure
(Oblique fissure)
from 2nd thoracic spine downward
and laterally, then anteriorly and
medially to the sixth rib in the
midclavicular line
the upper border of the lower lobe
• Minor interlobar fissure
(Horizontal fissure)
a horizontal line from the sternum at
the level of the fourth costal
cartilage to meet the line of the
major interlobar fissure
the boundary between the upper and
middle lobes
EXAMINATION OF THE
CHEST
Inspection of the chest
Palpation of the chest
Percussion of the chest
Auscultation of the chest
Inspection of the chest
Appearance of the chest
Bilaterally symmetrical and elliptical in
cross-section
Kyphosis — forward bending
Scoliosis — lateral bending
Flattening — PA diameter < half of the
transverse diameter
Over-inflation (barrel-shaped chest) —
PA diameter (in COPD)
Movement of the chest
Symmetrical
Venous pressure
right heart failure
obstruction of the superior vena cava
Respiratory rate and rhythm
14-16 breaths/min
Tachypnea
Cheyne-Stokes breathing
Cheyne-Stokes respiration
Obstructive apnea
obstruction of the upper airways by
soft tissues in the region of the
pharynx, apnea despite continuation of
respiratory effort
Palpation of the chest
Chest expansion
The examiner’s hands should be
placed over the lower anterolateral
aspect of the chest with the thumbs
along the costal margin, each pointing
toward the xiphoid process, and the
palms and fingers extended over the
anterolateral wall
• Expansion should be tested during both
quiet and deep inspiration
Method
1. The middle finger of one hand (usually
the left if the examiner is right-handed)
is pressed firmly against the chest wall
parallel to the ribs but with the palm
and other fingers held off the skin
2. A very short quick blow is struck at the
middle phalanx of the pleximeter finger
with the tip of the middle finger of the
right hand
3. When properly performed, the forearm
is virtually stationary the entire
movement being executed from the wrist
Notices
1.the plexor finger should strike the
pleximeter finger only instantaneously
and must be immediately withdrawn
2.compare one side of the thorax with
the opposite side as you proceeds with
the percussion
3.be sensitive to the vibratory sensations
that are being received from the chest wall
by the pleximeter finger
Percussion note
Resonance
Dullness (reduction of resonance)
short, high pitched, not loud, the
pleximeter finger perceives relatively
little vibratory sensation
1. Consolidation: the underlying lung
more solid than usual
2. Pleural effusion: the pleural cavity
contains fluid
3. Pleural thickening
Hyperresonance (increase in
resonance)
Pneumothorax: the pleural cavity contains
air
Auscultation of the chest
The breath sounds
Normal breath sounds: vesicular
Reduced: emphysema, pleural thickening
or pleural effusion
Bronchial breathing: louder, harsh, the
expiratory sound has a more sibilant
character than inspiratory sound
consolidation of the lung (pneumonia)
Added sounds
Stridor
The noise is often both inspiratory
and expiratory
Associated with laryngeal disease
or localized narrowing of the
trachea or the large airways
Wheezes
musical sounds associated with
airway narrowing
Widespread polyphonic wheezes
dynamic compression of the bronchi
accentuated in expiration when
airway narrowing is present
diffuse airflow obstruction, as in asthma
and COPD
Fixed monophonic wheezes
localized narrowing of a single bronchus
by a tumour or foreign body
may be inspiratory or expiratory or both
Crackles
Short, explosive sounds, produced by
sudden changes in gas pressure related
to the sudden opening of previously
closed small airways
COPD: crackles at the beginning of
inspiration
Bronchiectasis: localized loud and
coarse crackles
Diffuse interstitial fibrosis: fine and late
inspiratory crackles
The pleural rub
creaking or rubbing in character
Pleural inflammation
associated with pleuritic pain
Vocal resonance
The resonance of sounds in the
chest made by the voice (the
vibrations transmitted from the
vocal cords to the chest as the
patient repeats a phrase, ‘ninety-
nine’)— detected through
stethoscope
Not distinct syllables but a resonant
sound