Respiratory system physical examination

what should we know before:

emphysema( pol. ROZEDMA)- chronic pulmonary disorder characterized by abnormal increase in air spaces on the periphery of terminal bronchi and destruction of terminal bronchi's walls. This results in hyperventilated lungs with dimished number of alveoli. Irreversible condition, the main sign is dyspnea. Results from cigarette smoking and environmental air pollution.

COPD ( pol. POCHP)- chronic obstructive pulmonary disease ( przewlekła obturacyjna choroba płuc)is a lung disease defined by persistently poor airflow as a result of breakdown of lung tissue (known as emphysema) and dysfunction of the small airways. Primary symptoms include: shortness of breath, cough, and sputum production.

COPD is most commonly caused by tobacco smoke. This triggers an inflammatory response in the lung. COPD is often defined based on low airflow on lung function tests. In contrast to asthma, this limitation is rarely reversible and usually gets worse over time.

atelectasis (pol. NIEDODMA)- is defined as the collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation. Acute atelectasis may occur as a post-operative complication or as a result of surfactant deficiency. In premature neonates, this leads to infant respiratory distress syndrome.

asthma (pol.astma)- is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction and bronchospasm. Common symptoms include wheezing, coughing, chest tightness, and shortness of breath. Asthma is thought to be caused by a combination of genetic and environmental factors.

cystic fibrosis/mucoviscidosis (pol.mukowiscydoza)- is an autosomal recessive genetic disorder that affects most critically the lungs, and also the pancreas, liver, and intestine. It is characterized by abnormal transport of chloride and sodium across an epithelium, leading to thick, viscous secretions. Lung disease results from clogging of the airways due to mucus build-up, decreased mucociliary clearance, and resulting inflammation. Inflammation and infection cause injury and structural changes to the lungs, leading to a variety of symptoms.

pleural effusion(pol.płyn w jamie opłucnej)- is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.

bronchiectasis (pol.rozstrzeń oskrzeli): is a disease state defined by localized, irreversible dilation of part of the bronchial tree caused by destruction of the muscle and elastic tissue. It is classified as an obstructive lung disease, along with emphysema, bronchitis, asthma, and cystic fibrosis.

Traditional sequence of examination:

1) inspection

#barrel chest- results from compromised respiration ( ex. in COPD, emphysema, cystic fibrosis). Ribs are more horizontal, spine is kyphotic, sternal angle more prominent. Trachea may be posteriorly dispalced. Anteroposterior diameter increases ( seen in cross-section of the thorax).

#kyphosis- posterior deviation of spine ( Gibbus=extreme kyphosis)

#scoliosis- lateral deviation of spine

#pigeon chest ( pectus carinatum)- prominent sternal protrusion

#funnel chest (pectus excavatum)- indentation of the lower sternum above the xiphoid process

#presence of cyanosis/pallor- skin, nails, lips, nipples

#presence of supranummerary nipples- may indicate some congenital abnormalities

#smell the breath ( can be done along with auscultation)- intrathoracic infection can make it malodorus ( stinking)

-sweet/fruity: diabetic ketoacidosis

-fishy/stale- uremia

-ammonia-like-uremia

-musty fish/clover- fetor hepaticus: hep.failure, portal vein thrombosis, portacaval shunts

-foul/feculent-intestinal obstruction, diverticulum

-foul/putrid-nasal sinus pathology

-halitosis-tonsillitis, gingivitis, vincent angina, gastroesoph.reflux

-cinnamon- pulmonary tuberculosis

#superficial venous patterns- may indicate some heart disorders or vascular obstruction

#symmetry of expansion

#presence of clubbing fingers

*determining respiratory rate:

-> should be 12-20 breaths/minute/ ratio of resp./BPM should be like 1:4

#normal- 12-20/min

#bradypnea- less than 12/min ( results from alkalosis, cns lesions[ cerebrum], myesthenia gravis, narcotic overdoses, extreme obesity)

#tachypnea- more than 20/min (results from acidosis, cns lesions[pons], anxiety, aspirin poisoning, oxygen need, pain)

#hyperpnea- faster than 20/min; deep breathing

#sighing (wzdychające)- frequently interspersed (przeplatane) deeper breaths

#air trapping- increasing difficulty in getting breath out

# Cheyene-Stokes- varying periods of increasing depth interspersed with apnea; kids and older adults may breath in this pattern during sleep

#Kussmaul- rapid, deep, laboured ( causing difficulties), associated with metabolic acidosis

#Biot- irregularly interspersed periods of apnea in a disorganized sequence of breaths; results from persistent intracranial hypertension, respiratory compromise resulting from drug poisoning or brain damage at the medullary level.

#ataxic- significant disorganization with irregular and varying depths of respiration

*other manifestations

#orthopnea-shortness of breath resulting when trying to lay down; using more pillows is helpful.

#paroxysomal nocturnal dyspnea- suuden onset of shortness of breath after sleeping period; sitting upright is helpful.

#platypnea- dyspnea resulting from overcoming the upright posture

2) palpation

-palpate thoracic muscles and skeleton seeking for pulsations, areas of tenderness, bulges, depressions, masses, unusual movement and positions.

-palpate thoracic expansion ( from the back, placing your thums on the spine, and other fingers on the lateral aspects of rib cage)

#crepitus- crackly and crinkly sensation, can be both palpated and heard, like a gentle bubbling feeling. Indicates air in the subcutaneous tissue from a rupture of somewhere in the resp. system or by infection with gas producting organism (ex. gas gangrene [pol. zgorzel gazowa] caused by clostridium perfringens)

#pleural friction rub- palpable, coarse, grating vibrations usually on inspiration; caused be inflammation of pleural surfaces

#evaluation of tactile fremitus- palpable vibrations of chest wall that result from speech and verbalization. Best felt parasternally in the 2nd intercostal space at the level of bifurcation of bronchi. ( ask patient to say '99' or 'mickey mouse' ) . Can be evaluated with whole palms or with ulnar aspects of hands.

->increased fremitus: indicates presence of fluids or a solid mass within a lungs ( tumour mass, heavy, nonobstructive bronchial secretions)

->decreased fremitus: may be caused by excess air in the lung, emphysema, pleural thickening, effusion, massive pulmonary edema, bronchial obstruction

#trachea examination- notice the position, deviation ( may be displaced due to atelectasis, thyroid enlargement, pleural fibrosis, pleural effusion and many others)

3)percussion

-can be evaluated bilaterally or topographically; intervals should be like 4 to 5 cm over the intercostal spaces

-can be performed directly with ulnar aspect of fist or indirectly with fingers

-patient should be seated backward with his head bent forward and arms folded in front ( this moves scapulae laterally, exposing most of the lungs)

-lateral and anterior chest should be percussed with patient's arms raised overhead

*hyperresonance: can be associated with hyperventilation so emphysema, pneumothorax, asthma

*dullness, flatness: can suggest atelectasis, pleural effusion, pneumothorax, asthma.

a)resonant->loud intensity->low pitched->long duration->hollow quality

b)falt->soft intensity->high pitched->short duration->very dull in quality

c)dull->medium intesity->medium to high pitched-> medium duration->dull thud in quality

d)tympanic0>loud intensity->high pitched->medium duration->drumlike in quality ( USUALLY ABDOMINAL)

e)hyperresonant-> very loud intensity->very low pitched->longer duration->booming in quality ( ABNORMAL- RESULTS FROM AIR TRAPPING ex. in COPD)

3)auscultation

-patient should be seated upright, breathing slowly and deeply through the mouth exagerrating normal respiration

-use the diaphragm of the stetohoscope cause it transmits high-pitched sounds better than a bell ( broader area of sounds)

*normal breath sounds

a)vesicular: heard over most of the lung field; low pitched, low-intesity, soft and short expiration. Diminished in overweight and very muscular patients.

b)bronchovesicular: heard over the main bronchus are and over upper right posterior long field; medium pitched and intensity, expiration equals inspiration

c)bronchail/tracheal: heard only over trachea; high pitched, loud and long exirations, sometimes a bit longer than inspiration.

other:

-amphoric: resembling the noise made by blowing across the mouth of a bottle, can be heard in stiff-walled pulmonary cavity or tension pneumothorax with bronchopleural fistula

-cavernous: sounding as if coming from the cavern, commonly heard over a pulmonary cavity in which the wall is rigid

BOTH BRONCHOVESICULAR AND BRONCHIAL BREATH SOUNDS ARE ABNORMAL IF HEARD OVER THE PERIPHERAL LUNG TISSUE!

*abnormal breath sounds

a)crackles (rales) [pol.trzeszczenia]: discontinuous; caused mainly by the presence of some secretions in big bronchi ( ex.bronchitis, pneumonia, bronchiectasis). Mostly present during INSPIRATION, may vanish after caughing. Caughing doesn't diminish crackles if they're a result of lung parenchyma disorder (ex. COPD)

b)rhonchi (snoring): continuous; deeper more rumbling, more pronounced during EXPIRATION, less discrete than crackles. Caused by the air passage through obstructed by thick secretion, muscular spasm. All rhonchi may at time be palpable.

c)wheezes [pol. świsty] : continuous, are caused mainly by bronchial constriction caused by edema, spasm, tumour or secretion. Are present is asthma (poliphonic, mainly in expiration, wide spreaded), bronchitis (can diminish after caughing, can have the inspiration component), chronic obstruction ( monophonic, caused for ex. by bronchial cancer)

d)friction rub [pol. tracie opłucnowe]: caused by friction of viscreal and parietal pleurae during inflammation. Resembles the sound of walking through the fresh snow.

e) stridor - caused by upper airway obstruction ex. laryngitis.