EXAMINATION OF

RESPIRATORY SYSTEM
 INSPECTION
 PALPATION
 AUSCULTATION
 PERCUSSION
 GENERAL EXAMINATION

CYANOSIS
 Central
 Peripheral
causes
 COPD
 Type 2 resp. failure
 Pulmonary fibrosis
 B. asthma
 Congenital cyanotic heart disease
 Pulmonary embolism
OEDEMA
Right ventricular failure—cor pulmonale
FACE
 Pink puffers
 Blue bloaters
 Congested neck veins
 Rashes
EYES
 Horner,s syndrome---ca. bronchus
 Chemosis---SVC obstruction
---COPD
NECK
Lymph nodes----TB
---lymphoma
--sarcoidosis
---malignancy
SKIN
 Rashes—herpes zoster
 Scars---previous operation,burns ,
biopsies
 Pigmentation—haemochromotosis
 Dilated veins---SVC obstruction
HANDS
 Cyanosis
 Clubbing---ca. bronchus
---TB
---empyema
---abcess
---fibrosing alveolitis
---bronchiectasis
 Wasting of small muscles of hand ---pancoast
tumour
PULSE
 Tachycardia---> 120/min—infections
---P.E
--B. asthma
--COPD
exacerbation
 Small volume
 Collapsing pulse—large volume bounding
pulse ,carbon dioxide retention --type 2
resp. failure
PULSES PARADOXUS
 Status asthmaticus
 Massive pulmonary embolism
 Tension pneumothorax
 EXAMINATION OF THE CHEST
Inspection
 A-P diameter
--pectus excavatum---funnel chest
--pectus carinatum---pigeon chest
 kyphoscoliosis
 respiratory movements---resp. rate-{14-18/min}
i:e –hyperventillation—DKA, PE
---hypoventillation—type 2 resp. failure
 Chyne stokes breathing---cyclical variation
in the depth of respiration with period of
apnoea.
 Use of accessory muscles---status
asthmaticus
 Tenderness—fractured ribs,metastasis ,
neuralgia
SHAPE OF THE CHEST
Pectus excavetum
Pectus carinatum
DILATED VEINS
SVC obstruction---Ca lung
Barrel Chest

AP Diameter = Transverse
Diameter
Shape: Pectus Excavatum
Pigeon Chest
Kifoskoliosis
Palpation
Trachea
4-5 cm of the upper trachea can be felt in the neck
between the cricoid cartilage and the sternal
notch.
 Pushed –pneumothorax
-pleural effusion
 Pulled—fibrosis
--collapse
Tracheal shift to right
 Chest expansion– normal up to 5 cm
-abnormal < 2 cm
 Apex beat
 Tactile fremitus
--Ask the patient to say 99
--you should feel the vibration transmitted
through the airways to the lung.
Rib excursion/Tactile fremitus
Tactile Fremitus

• Increased fremitus indicates fluid in the lung

or consolidation of the underlying lung tissue.
• Decreased fremitus indicates sound
transmission obstructed by
chronic obstructive pulmonary disease (COPD)
fluid outside the lung (pleural effusion)
air outside the lung (pneumothorax)
 Percussion
 The percussion note loses its normal
resonance when ever aerated lung tissue
is separated from the chest wall by fluid or
pleural thickening .
OR
 When lung tissue is separated from chest
wall by collapse or consolidation or fibrosis
 Increased in---pneumothorax
--emphysema
 Decreased---pleural effusion
 Auscultation

Breath sounds—
 Vesicular—normal
--insp. twice that of expiration
--no pause
 Bronchial –inspiration is shorter than expiration
---gap between insp. and exp.
 Normal breath sounds: Vesicular

; soft, low, heard in periphery and base of lungs.

 soft, low, heard in

periphery and base
of lungs.
Normal breath sounds:
bronchovesicular

 medium pitch,
heard between
scapula and
anteriorly close
to sternum.

Copyright © 2000 by W. B. Saunders Company. All rights reserved.

Normal breath sounds: bronchial

 loud and harsh; heard

over trachea.
Abnormal when heard
elsewhere
(pneumonia, tumor).
 Increased---consolidation
---large cavity near the surface
 Decreased---COPD
---Pleural effusion
--pneumothorax
Added sounds
 Crepitations---fine ---heart failure
--fibrosing alveolitis
---coarse—bronchiectasis
--infections
 Wheezes or rhonchi---COPD
--bronchial asthma
• Pleural rub
• Whispering pectroloquy---consolidation
--ask the patient to whisper 99
--you should hear only faint sounds or
nothing----if you hear the sound clearly
then this is referred as whispering
pectroloquy.
Adventitious (Added) sounds
Discontinuous Sounds (Crackles/Rales/Crepitations)
Fine crackles occur in inspiration and are soft, high-pitched,
brief sounds (5-10msec).
- be imitated by rubbing some hair between your fingers near your
ear.
- occur due to the 'popping' opening of small airways that
were closed prematurely at the end of the previous
expiration.

Coarse crackles are somewhat louder, lower in pitch and not quite so
brief (20-30msec)
- occur when there is fluid in the larger bronchi.

•
 Crackles…

• Listen for the following characteristics:

• Loudness, pitch and duration
• Number ( few to many)
• Timing in the respiratory cycle
• Location in the chest wall
• Persistence of their pattern from breath to breath
• Any change after a cough or a change in patient’s
position
Crackles

May be due to abnormalities of the lungs or of the airways.

If they occur early on in inspiration reflect bronchiectasis or chronic
bronchitis. If they occur later in inspiration, then they may be due to
restrictive conditions of the lungs such as pneumonia, fibrosis or
pulmonary edema.

• Typically if it is associated with Pulmonary Oedema and Fibrosing

Alveolitis affect both lung bases equally, whereas in pneumonia and in
mild bronchiectasis the crackles are localised.

• Bear in mind that normal individuals may have a few basal crackles
after maximal expiration. Can also be heard in dependent portions of
the lungs after prolonged recumbency. These often clear on coughing.

• Early inspiratory crackles are heard most often in chronic bronchitis

and emphysema, are fairly coarse, and change with coughing.
Adventitious sounds

Wheezes – high-pitched, with hissing or shrill quality

- predominantly expiratory sounds that reflect localised
narrowing of the airways. Asthma and Chronic bronchitis
are the most common causes. Occasionally, they may occur with
pulmonary oedema.

Stridor is an inspiratory wheeze associated with upper airway obstruction

(croup) caused by a foreign body or possibly a tumour.

Rhonchi - relatively low-pitched, ften have a "snoring" or "gurgling" quality.

Any extra sound that is not a crackle or a wheeze is probably a rhonchi
which suggests secretions in large airways.
Adventitious sounds

• Pleural Rub –
- squeaky to- and fro-rubbing sound
- occurs when inflamed surfaces of the pleura rub together.

Causes include pleurisy (a virus or bacterium infects the pleurae),

pneumonia and pulmonary embolism, etc. They usually occur in
inspiration and in expiration.
Clinical features Of Lung Cancer
 Clinical features
• There are no symptoms of early lung
cancer in some patients.

• Symptoms caused by lung cancer are

non-specific:
– wheeze or a slight cough,
– symptoms of infection (fever ,purulent
sputum) ,
– obstruction (wheezing,dyspnea)
– ulceration of bronchial mucosa (hemoptysis).
 Clinical features
1.Respiratory symptoms
(1).Cough
(2).Hemoptysis
(3).Dyspnea
(4).Wheeze or stridor
(5).Chest pain
(6).Fever
 Clinical features
2.Symptoms caused by the near organs or
tissue involved by tumor
(1)Dysphagia
(2)Hoarseness :invasion of the recurrent laryngeal
nerve
(3)Pleural effusion due to invasion of the pleura.
 Clinical Features
(4)Horner’s syndrome.
Invading the cervical sympathetic ganglia
myosis, ptosis, exophtalmus and no sweat
of the face.
(5)Pericardial effusion
 Clinical fetures
(6)Superior vena cava syndrome. Due to
obstruction of the superior vena caval,the patient
may have noticed that his collar is tight, the neck
is enlarged and the jugular vein and the veins of
anterior chest wall are distension and edema of
the face.

3.Symptoms caused by metastasis.

liver, skeleton,brain, supra clavicle lymph nodes.
 Clinical fetures
4.Paraneoplastic syndrome
Because tumor cell can secrete ectopic
hormone，antigen or enzyme the patients
with Lung Cancer sometimes may have
some paraneoplastic syndrome Including:
(1) Collagen tissue disorder such as finger
clubbing , hypertrophic pulmonray
osteoarthropathy
 Clinical features
(2)Endocrine disorders including Cushing’s
syndrome ,syndrome of inappropriate
antiduretic hormone secretion(SIADHS),
(3) Neuropathic or myopathic disorders
including polyneuritis ,cerebellar
degeneration,mental abnormalitis