The patient remains sitting up erect for almost all of the examination .
He / she should ideally be made to stand during inspection .
He/ she should be supine only momentarily during examination of shifting dullness .
If the patient is too sick to sit up himself / herself then he/ she can be propped up with a backrest to as vertically as possible .
We usually make him/ her sit on the bed and we ask him / her to turn as necessary . Actually he / she should be sitting on a tool so that we can walk around him / her . A lot of external examiners actually want to see you use a tool .. take note .
Even sitting up erect is not enough . He / she must be sitting up straight / erect , both upper limbs by the side , not leaning on his/ her side or his ) her limbs , not stooping or bent in any direction . You must take a minute to explain this to the patient and achieve this posture and actually use your hands to adjust him/ her to get it right . This is essential during Inspection and Palpation . Percussion and Auscultation have postural issues too but not like the first two . If the patient is sick ask us for a backrest .
Patient exposure The full chest must be exposed front and the back . So all female patients shall need a screen and boys shall ask us for a female attendant if they have to examine a female patient . Remove any thick undergarments like thermocot , bras, sweaters which simply do not allow examination . If you don’t remove them before the examiner comes it’ll look like you haven’t examined her adequately . Remember you pass on correct methods first then on correct findings .
Your position Stand on the right side of the patient as always . Now let’s come to Examination proper … Before we proceed note that we are looking for a diagnosis which has three and often four parts : anatomical part , aetiological part , pathological part and complications if any . The examination of the chest , among other things is excellent for finding the type of pathology which in your case is often ( not always ) something unilateral . Common pathologies you encounter when examining a Respiratory patient are , pleural effusion , consolidation of the lung , fibrosis of a lung or lobe , collapse of a lung or lobe , pneumothorax , hydropneumothorax . So while examining keep thinking about the possible pathology …you shall have a more focused and fruitful examination . This session is for methods …shall discuss interpretation of findings after this is done .
Examination of the respiratory system has four parts all of which carry importance .
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
INITIAL STEPS Follow the steps .Explain very very briefly what you are going to do ( don’t scare the patient with details , just politely inform him/her that he / she shall be examined ). As always done.
Take consent As always done .
Achieve adequate exposure as described above . 4. Achieve a proper position as described above . Now you can start Inspection . Keep in mind possible DD from a pathological point of view . INSPECTION
Shape of the Chest Normal A normal adult chest is : a. Bilaterally symmetrical b. Elliptical in cross section c. The transverse : anteroposterior diameter is 7:5 Abnormal Abnormalities in the chest shape can be unilateral or bilateral . Bilateral ones include : eg a. Barrel chest :where the transverse :AP diameter is 1:1 like a barrel due to air trapping seen in COPD patients . b. Pectus excavatum ( funnel chest //see book for details) c. Pectus carinatum (pigeon chest // see book for details ) Unilateral changes : specially look out for these .. They are either a bulge of one hemithorax or a depression of the same . Thus we have to compare both sides of the chest from the front and the back . And this is why the patient must be sitting up or standing and maintaining a symmetrical position . Standing is preferable during inspection . Sitting is enough for all other steps . If an obvious difference is not seen on gross Inspection look area by area . Compare bilaterally : a. The supraclavicular area b. The infraclavicular area c.The mammary area d. The inframammary area Look for a local bulge or depression . Compare how prominent the intercostal spaces are side to side . This is done for the anterior and the posterior chest . The lateral chest is difficult to see …it is omitted at times . Now there are a few extra things to see posteriorly in relation to shape . These are assymetry in the bony structures bilaterally . a. Look for kyphosis and scoliosis b. Compare the scapula position bilaterally c. Look for shoulder drooping .ie ..one acromion process being higher or lower than the other . This is best seen from the back and always standing.
Movement of the chest . It is best scene together with shape at the same time . One should look anteriorly and posteriorly . Sometimes it is difficult to say which side has the abnormal shape , specially when the findings are subtle ( this is often the case ) However , the movement of the chest can only be decreased by a pathology , not increased . So the side which is not moving well / or at all is the abnormal one .
Respiratory rate Count the rate for a full minute The patient should be at rest . Similarly give him ) her rest if he/ she has just walked in from somewhere . Preferably , the patient should be unaware of you counting his / her rate to avoid an anxiety related increase . Check several time if you can .
Respiratory type To see this just note and compare the respiratory movement of the chest and abdomen . Normally , In males : Abdomino – thoracic ..ie the abdomen moves first In females : Thoraco- abdominal … the thorax moves first In children : Abdominal ..mostly abdominal movement
Accessory muscles of respiration moving or not
Trail’s sign Tracheal position is strictly speaking a palpatory finding . But when it is grossly shifted to one side , the clavicular head of the sternocleidomastoid muscle on that side becomes very prominent . It thus indicates gross tracheal shift .
PALPATION First note that : The entire process must be done sitting upright or at least propped up if very sick . We try to confirm the inspectory findings plus get new information. Following steps :
Palpation of the trachea and apex beat for mediastinal shift if any . The mediastinum is the space between two lungs . This space can shift to one side incase of certain lung pathologies which can ‘ pull ‘ or ‘ push ‘ . The trachea represents the upper mediastinum , the apex beat ( ie cardiac position , the lower mediastinum ) . A lot of pictures should be provided for clarity . Shall send pictures at the end of the text . A. Palpation of the trachea Following steps are followed : 😊😊 a. The patient remains sitting upright or propped up if he/ she is is very sick . b. We stand on his / her right side ( assuming that we are right handed ) and fix the head with the left hand by placing it centrally over his/ her scalp above the forehead. We thus hold the head straight . c. Now we first extend the neck to make the thyroid cartilage ( Adam’s apple ) more prominent . d. Having noted it’s position , we put the head in a neutral position or just slightly flex the neck . e. We place the tip of the index finger over the centre of the thyroid cartilage, the right hand being straight and the finger being vertical in position . We gradually descend along the centre of the neck towards the suprasternal notch , along the way we feel the cricoid cartilage and then the cartilaginous rings of the trachea in sequence . f. Instantly it becomes obvious if the tracheal rings are oriented in a straight line or are deviating to one side …that reveals tracheal deviation to that side . g. On reaching the suprasternal notch we now very very gently insinuate the tip of the palpating index finger into the gap between the lower end of the trachea and the sternal head of the sternocleidomastoid on either side . The difference in the gap ( the gap is larger opposite to the side of deviation ) reveals tracheal deviation to one side . h .In an alternative method , we use the tip of the middle finger instead of the index while placing the tips of the index and ring finger over the two sternal ends of the clavicles for support . B. Palpation of the apex beat ( location only ) a. Only here do we make the patient supine to assess the location of the apex beat . Character is not necessary here . b. As described under cardiovascular system examination .
Palpation of the lungs to assess movement of different parts of the lungs … Now , before we proceed , we divide the lung , anterior , lateral and posterior surfaces into 8 areas. all definitely by arbitrary lines for the purpose of easier description of findings . Anterior Infraclavicular area- just below the clavicle on either side , approximately on either side of the manubrium .. Mammary area – below the infraclavicular area , occupying approximately the area filled up by the pectoral muscles or by breast tissue . Inframammary area – below the mammary until the subcostal margin Lateral – Axillary – Approximately the upper half of this region Infraaxillary – Approximately the lower half Posterior Suprascapular – The part above the scapular spines . Interscapular – The part between the medial borders of the scapulae Infrascapular – The part below the interscapular area . Now to assess , movement .
Anteriorly , A. We place the palm of both our hands simultaneously over the infraclavicular and mammary areas outside the midclavicular line ( because the heart is present medial to this line and there isn’t much lung tissue or movement ) . Our wrists must be relaxed and not unduly extended so we must adjust our posture accordingly ( we may need to bend down or sit down ) Thus we can compare the rise and fall of the anterior chest wall on either side .. a pump handle movement as it is called . B. We attempt to grip the lower chest ( Inframammary area ) bilaterally and simultaneously our thumbs being close to the midline and holding a pinch of skin between them ( chhobi dichchi soon ) . We now compare the movement , bucket handle movement of the lower ribs . Our grip must be optimum , not too tight or too loose . Posteriorly , A. Movement at the apex We cup our fingers over the medial aspect of either shoulder , over the trapezius muscle , just lateral to the root of the neck , and try to insinuate a finger or two into the supraclavicular hollow behind the clavicle , also called Kronig’s isthmus . Our thumbs remain free and are held side by side and parallel to each other . When the patient breathes the thumbs move up a down plus the fingers in the Kronig’s isthmus can feel any difference in movement . B. Movement of the infrascapular area . Just like the inframammary region . C. The Interscapular area usually isn’t palpated . There are variations among examiners and books which we shall discuss later .
Vocal fermitus a. When we speak , vibrations are palpable over our chest …that is called vocal phremitus . b. We compare side by side , area by area as we did with movement discussed above . c. However we use any one hand for assessment of phremitus because the sensitivity of both hands might differ . So we place our hand over the infraclavicular , of the normal side ( right or left ) then the abnormal side , then the normal mammary then abnormal then inframammary , axillary , Infraaxillary , suprascapular , Interscapular and infrascapular in sequence .. normal followed by abnormal . COMPARING NORMAL WITH ABNORMAL IS A BASIC RULE FOR MOST EXAMINATION SPECIALLY RESPIRATORY AND NEUROLOGY . SEE THE NORMAL SIDE FIRST IS A RULE c. We use the palm of the hand of our choice or base of the fingers . d. The patient says 9 ,9,9 ” . He / she is instructed to say it in a normal voice and at the same intensity every time , not to shout or whisper . e. We compare findings .
Chest Expansion . a. The patient holds his / her arms stretched vertically above his / her head for this examination. The idea is to remove as much pectoral muscle tissue and breast tissue as possible because they can give a false impression of chest measurement. b. We use a standard measuring tape . c. The measurement is taken at the level of the nipples in men and just below the breasts in women. d. We take two measurements …the first in full expiration and the next after holding breath after a full inspiration . The difference gives the chest expansion. e. We preferably take the measurement in expiration , then ask him / her to inspire and let the tape slide to get an accurate measurement , rather than take it twice separately .
Local temperature Just use the dorsum of your hand to compare the surface temperature on either side , area by area as mentioned above . Differences might be found in local inflammation .
Tenderness a. Do this area by area , side by side , normal side first as described above . b. Use the palm of your hand and gently roll it over the respective area . c. Observe the patient’s face for any signs of pain on your touch , that is tenderness (remember that pain is a symptom , tenderness is a sign ) .
PERCUSSION .. Consider the following aspects first a. Memorise the LAWS OF PERCUSSION … go to Arup Kundu and see b. If you are right handed , the middle finger if your left hand is the pleximeter finger ( you strike this finger ) while the middle finger big your right hand is the percussion finger ( you use this finger to strike the other ) . Some students prefer the index finger of the right hand as the percussion finger …it’s acceptable .. c. It is the opposite for the left handed . d. Please learn to percuss and practice with one finger ( Don’t use two or three fingers bunched up together… It simply isn’t allowed ) e. You shall strike the middle phalanx of the pleximeter finger . f. The entire pleximeter finger , but specially the middle phalanx is pressed FIRMLY over the chest . Firm pressure is essential because :
It gets you closer to the lung across the chest wall by compressing soft tissues as much as possible .
It eliminates any air space So please place it firmly . Getting a good sound is more about technique . Though it is true that fellows with huge hands often get away with a fair sound without much technique … Size does help but people with small slim fingers can do it well too .. g. Please put your pleximeter finger in the intercostal space … accurate placement is essential to getting a good sound … Now to strike with your percussion finger . h. You must have neat clipped nails … Long nails and nail polish are frowned upon …plus percussion with long nails actually hurts . g. Use the bony tip of your finger to hit the pleximeter . Most of you tend to casually use the soft pulp at the tip of your finger which never hurts but never gives you much of a sound !? Good percussion does leave a red mark which hurts a bit too often . The finger tip must land perpendicular to the surface of the pleximeter . h. Hit the centre of the middle phalanx , never hit the interphalangeal joint …you get far less sound and hurt yourself much more than necessary . i. You need not hit with extreme force… Hitting too hard reduces accuracy… You look like a fool hitting very hard but not eliciting much sound . Focus on accuracy and an EVEN STROKE … practice so that you hit in exactly the same way with about exactly the same force each time .. j. Certain situations call for light percussion and certain for heavy..if you can you may even practice light and heavy percussion separately and develop two different strokes . It’s not essential but it is useful and worth it . k. Your hand must move from the wrist … The weight of your hand plays a role in percussion . Most of you initially do violent elbow movement with a stiff wrist … Learn to stiffen the elbow and release the wrist … Actually a lot of medical techniques call for good wrist movement and hand work .. l. Now to use what has been discussed above we shall percuss the anterior wall, the lateral wall and the posterior wall separately . m. Anterior wall
The patient sits up straight with both arms hanging freely on either side .
You shall percuss from above downwards the clavicle , the infraclavicular area , and then from the second to the sixth intercostal spaces . 3. Clavicular percussion a. This is direct bony percussion ..no pleximeter is necessary ..just strike the clavicle . b. You hit at the junction of the medial one third and lateral two thirds of the clavicle .. this is the most prominent part of the clavicle . c. Use your other hand to pull down the skin below the clavicle so that your percussion finger doesn’t slip .
All further percussion shall proceed in the midclavicular line .
Percuss the infraclavicular area …just one note below each clavicle.
Percuss all the intercostal spaces from the 2nd to the 6 th on either side in the midclavicular line .
Percuss the normal side first , then immediately compare with the abnormal side , space by space ..ie …left 2nd space , right 2nd space , left 3rd space , right 3rd space and so on until the 6th .. assuming that the left is normal .
Percussion over the right 5th and 6 th spaces to elicit liver dullness must be heavy percussion . Percussion of the lateral wall
The patient sits up straight with both arms held suspended above his head .
Percussion is in the mid axillary line
Percussion is from the 4th space to the 8 th space .
Just percuss , normal side first , comparing side to side , space by space as discussed above . o. Posterior percussion A. Suprascapular area
First we percuss the suprascapular area .
This is the area above the scapular spines . Note that the lateral part of each is more shoulder joint. You must focus on the medial half of each , near the trapezius muscle .
You percuss , thrice on either side of the midline , comparing as you go space by space . 4. Your pleximeter fingers must point upwards and outwards .
The entire back has much more muscle than the anterior aspect and sides so percuss heavily … B. Interscapular area .
You must place the middle phalanx of the pleximeter just medial to the medial border of the scapulae on either side .
Place your pleximeter in the intercostal space with great accuracy …or you won’t get much sound .
The midline of this area has the spine where no sound can be produced plus a zone of about one inch or a bit more on either side occupied by the rather heavy erector spinae muscle over which percussion would be frustrating . Hence we get near but not on the scapula .
Proceed downwards , space by space , comparing as you go . Note that the ribs are initially horizontal but tilt downwards and outwards as you descend .
Follow whatever has been discussed but percuss heavy . C. Infrascapular area
You do exactly what you have done for the Interscapular area and proceed as far down as you can …the 10 th space .. Note that the ribs tilt much more now . This entire combination of changing direction of the pleximeter to match with the ribs is called a ‘herring bone’ or ‘ fish bone ‘ pattern . p. Percussion for shifting dullness
Examine carefully and note the abnormal side first
We now percuss the anterior wall ( this is more commonly done ) or the posterior chest wall from above downwards using the methods described above .
Note where the upper resonant or hyperresonant sound is replaced by a dull sound ( Shall explain dull and resonant soon … resonant is caused by a normal air filled lung … Dull by effusion or consolidation )
Now make the patient supine to examine his anterior chest wall again or prone if you need to see the posterior wall . 5 .In case of shifting dullness , the dullness is replaced by resonance . ( Shall explain the theory behind this soon )ie the entire anterior chest wall is now resonant . Remember percussion is often asked by the examiner to test your skills …it’s something you need to learn well … You. need to look like a pro ..so practice hard Shall demonstrate when I get the chance …use videos for now .. Kal continue korbo … Bye for now AUSCULTATION
There isn’t much to say about in the methods of auscultation ….but the findings need much discussion
We always use the diaphragm and almost never use the bell .
As in examination of the cardiovascular system , we apply the diaphragm with a certain amount of pressure . Merely occluding the gap between the stethoscope and the chest wall won’t do …a certain amount of pressure really improves the intensity of sound .
The patient should be undressed, as mentioned at the beginning of this discussion and the stethoscope in contact with bare skin . It is possible to hear fairly well through thin garments but : a. It is protocol to hear without clothes … Examiners shall be annoyed if you don’t . b. Certain fabrics are too thick to allow adequate sound passage . Others like some nylons create a scratchy sound mimicking abnormal sounds eg crepitations. c. You can see better exactly where you are placing your diaphragm .
Normal quiet respiration in a normal individual is truly quiet and very difficult to hear . Therefore we must instruct the patient to breathe quickly and deeply with an open mouth . a. We need to demonstrate this to the patient ..to breathe a little forcefully with mouth open . b. Opening the mouth often eliminates unwanted grunting sounds which a lot of people make while breathing . At the same time you must give the patient rest between sessions of auscultation .. he/ she is a patient and prone to dyspnea on mild exertion .
Stand to one side so that the patient , breathing forcefully , does not exhale into your face . For the same reason learn to auscultate standing as straight as the length of your stethoscope will allow rather then bending of your patient and exposing yourself . Some students actually , though unconsciously lean on their patients and drop their body weight on them while examining …this is inappropriate .
Examine the anterior chest , lateral chest and posterior chest separately ..
Always examine one intercostal space at a time and immediately compare with the opposite side before moving on to the next space .
Always start from the top moving down slowly 10. Always start with the normal side first
Take time to examine . After placing your diaphragm with pressure listen to at least two respiratory cycles , the inspiration and the expiration before moving to the next space. Common mistakes you make are that you go too fast and forget to hear the inspiration or the expiration .
Take time to examine . Hear the sound till the very end . Often it is at the very end of expiration and only on forced breathing that you will hear those crepitations or rhonchi which are essential for diagnosis . Give maximum time to auscultation . A .It is most laborious . B. Needs most practice . C. But it gives you the best most diagnostic findings .
You may record your findings spacewise or areawise . Areawise is always quick and convenient , specially when you aren’t so sure about the spaces but at time you need to know the exact space of a finding. It ok to try and be a bit wrong …no UG should fail for being a space off target . 14 .The space scheme is similar to percussion Anteriorly Below the clavicle 2nd intercostal space to 6 th intercostal space bilaterally . Stay on or just outside the midclavicular line . Laterally From the 4 th to the 8 th space in the midaxillary line . Posteriorly The entire back from suprascapular , interscapular to infrascapular , space by space , staying away from the midline ( where the heavy musculature is a hindrance to auscultation ) and finally moving a bit laterally in the infrascapular area . 15 .If you find an abnormal sound, investigate that area thoroughly , search around with your stethoscope , it’s like inching in cardiovascular examination but much more laborious . 16 .Till you come back to the ward , please try to practice at home . It takes a long time to get used to it . Do the following . a. Listen to the normal sound with quiet breathing . b.Then listen with forceful breathing and note the difference . c. Listen to the a breath sound over the chest and compare the length and the changing intensity of the inspiratory sound and the expiratory sound . Note how the sounds increase and decrease , how the expiration fades away .This is a normal vesicular sound . d. Similarly auscultate over the trachea , note the harshness , the similar length of inspiration and expiration , and the obvious gap between the two phases not found in a vesicular sound .This is what a bronchial sound is like . e. Rhonchi are whistling sounds .. Crepitations are like crackling . Shall continue tomorrow or Tuesday with a discussion of findings . Bye for now RESPIRATORY SYSTEM EXAMINATION FINDINGS : INSPECTION
Generalised shape change Possibilities a. Barrel chest b. Pectus Excavatum c. Pectus Carinatum The last two are congenital are rare …see textbook images .. The first one is really common and a feature of many long standing COPD / Emphysema patients .. It simply means that the chest had an approximately circular cross- section .. ie. the transverse to antero-posterior diameter is 1:1 . The proper way to measure this is with special calipers , which look somewhat like our Vernier callipers but are much bigger and certainly not available here … Here we use large pieces of cardboard eg hardbound copies to do it .. Do it if you are actually asked .
Assymetry when comparing both sides of the chest .. This is the finding that you must train your eyes to look for.. it instantly reveals a possible diagnosis and narrows down diagnostic possibilities . The finding is that one side shall be bulged or depressed compared to the other side . Bulging can be caused by an effusion or a pneumothorax .. Depression , by a fibrosis or lung collapse . Consolidation causes no obvious shape change . Changes are subtle in most patients …often you need to finish the examination and compare and correlate Inspection with palpation , percussion and auscultation to make a final correct decision .
Movement … The side which doesn’t move or moves less is always abnormal …it is very helpful when inspectory findings are subtle ..
Respiratory rate .. Normal is 15-18 some books , slightly different in others …memorise from one book and use at the bed side … Most of your patients shall have a normal rate or an increased one … Read the causes of all possible findings 5. Respiratory type Normally , Adult males : Abdomino- thoracic Adult females : Thoraco-Abdominal Children : Abdominal
Trail’s sign It indicates the side of tracheal deviation .. It can be pushed by an effusion or pneumothorax or pulled by a fibrosis or collapse . Consolidation doesn’t cause this .
Accessory muscles of respiration working or not If yes it just indicates dyspnea , whether the patient admits it or not . PALPATION
Tracheal position As mentioned in Trail’s sign .
Position of the Apical impulse It too is pushed by a effusion or pneumothorax and pulled by a fibrosis or collapse but not affected by a consolidation .
Movement Reduced by all pathologies … No one increases movement.
Vocal phremitus Increased only by consolidation . Decreased by everyone else . 5. Chest expansion Decreased by all pathologies 6. Temperature Can be raised by any inflammation of severe enough Say , an Empyema or a consolidation with associated overlying pleural involvement .
Tenderness Think anatomically Bones: lung cancer spreading to a bone can cause bony tenderness … Otherwise localised chest wall tenderness.. due to inflammation as stated in temperature . Shall finish percussion and auscultation in 1-2 days then move on to GI system .. and then neuro … After that we shall discuss individual long cases ..shall do general survey too sometime .. Bye for now EXAMINATION OF THE RESPIRATORY SYSTEM FINDINGS PERCUSSION First of all , Percussion findings are difficult to elicit without lots of practice , but very definitive when found . So ,
Please practice at home on each other . It’s all you can do now .
Try to develop an even stroke … Which means that every note you strike is done in exactly the same way with the same force , producing a similar sound each time .. That should be enough to see you through when you finally get to practice on a patient .
Just remember that it is an examiner’s favourite. Don’t ignore it . NORMAL The normal note , if properly elicited is called RESONANT . It is a low pitched hollow sound . It is produced by a lung FULL of AIR Never use the word tympanitic when describing respirator percussion …this word should only be used for abdominal percussion …the normal note of percussion of an Abdomen is Tympanitic . At least get used to this sound …then you should be able to detect differences . 😊😊 Percuss on yourselves . ABNORMAL
HYPERRESONANT This sound is produced by a lung that is too full of air . It is a sound somewhat louder and clearer than the normal resonant sound . But without practice it sounds almost the same …but this can be overcome as shall be discussed later . Never mistakenly call it tympanitic . Three most obvious causes are a. Pneumothorax b. Hydropneumothorax ( the upper part only obviously) c. Emphysema . The first two causes usually give a unilateral finding while the third cause is almost always bilateral .
DULL This simply means that there is no sound on percussion , because the lungs ) alveoli are airless . This should not be too difficult to get It is the most common abnormal finding you shall get . However it can often be caused by faulty technique , so be careful… Be meticulous. It is caused by two main pathologies . a. Pleural Effusion b. Consolidation c. Empyema ( which is essentially a pus filled effusion ) There are two types of dull a. Stony dull b. Woody dull It doesn’t mean that they feel exactly like wood or stone … Medicine is full of very colourful , poetic and bizarre descriptions … Just understand them , memorise them and overall get used to them . This difference lies in how the lung feels when you percuss. a. Effusion ( and Empyema ) Feels stony. The fluid has compressed almost the entire lung and certainly the peripheral part , so there is no air to produced that resonant note . Rather it has been replaced by fluid. Fluid is non- compressible and therefore when percussed , the pleximeter finger feels a firm resistance , even pain , with every stroke , because fluid does not give way . b. Consolidation Feels woody . Here , the alveoli are full of exudate . So once again , there is no air to create resonance , hence dull . But because the alveoli are full of exudate which is soft and obviously compressible, this time the pleximeter finger feels no extra resistance on percussion . Hence woody dullness .
IMPAIRED This finding is somewhere between resonant and dull . It is due to partial replacement of the lung air by the pathology but some air is still available to create a lesser degree of sound on good percussion . It is a difficult finding. The two causes are a. Lung fibrosis b. Lung collapse Lung fibrosis In lung fibrosis , the alveoli are largely replaced by fibrous tissue . Any remaining alveoli , if sufficient can produce some degree of sound ie .. impaired . Lung collapse Collapse is of two main types a. Absorption collapse b. Compression collapse Compression collapse happens when the lung is compressed by an external physical force as in a pleural effusion or a pneumothorax . Here , however , we are referring only to an absorption collapse which is caused by significant blockage of a major bronchus or even one of the two main bronchi . Air can no longer flow in or out ,or maybe in a very very small amount. Gradually , the oxygen of the air and eventually the nitrogen and CO2 are all absorbed into the circulation and tissues while very little air can actually get in replenish it . This causes a partially deflated lung or a lung with absorption collapse . These are the few percussion findings .. Shall continue with auscultation over a 2 -3 more days … Bye for now EXAMINATION OF THE RESPIRATORY SYSTEM FINDINGS AUSCULTATION Auscultation is most difficult , requires the most practice but gives you the best findings . Give more time to your auscultation than any other method of examination . There are several possible findings on auscultation of the respiratory system . They are
Vesicular breath sounds These are the normal sounds we hear over most of the lung fields on auscultation . Let us describe them point by point : a. They are low pitched sounds ,yet we prefer the diaphragm rather than the bell for respiratory auscultation . 😊😊 b. The inspiration is longer than the expiration … AS HEARD c. There is no gap between the end of inspiration and the beginning of expiration . d. It is normally heard over most of the lung fields , better over the peripheral areas but over certain central areas it may be replaced by bronchial breath sounds as the normal sound ( discussed subsequently ) First , let us discuss the physiology of production of this sound in a normal lung . A. Air flows from the mouth via the trachea and then ultimately upto the alveoli for gas exchange. From the two major bronchi to the alveoli , there are 23 divisions of airway . The first 16 divisions are the conducting zone of the airways which are meant for airflow alone and not for gas exchange . The last 7 are called the exchange zone which are meant for has exchange ( alveoli , alveolar ducts , alveolar sacs ) . The initial sound is produced as air enters the trachea with some turbulence . This sound is a mixture of both high and low pitched components . However , the airways , specially the alveoli act as a filter , they remove the high pitched sounds and thus we hear the vesicular sounds as low pitched . B. Airflow during inspiration is active while during expiration it is passive . Assuming that about the same amount of air flows in and out with each breath , inspiration should be completed more quickly than expiration . Infact , that is what actually happens . But remember that we are placing our stethoscope on the chest wall . As air enters during inspiration we hear the entire air flow ..air flowing into the alveoli . This is an active process so the air flow is faster and hence a bit more turbulent and louder . This is followed immediately by the onset of expiration ( hence no gap ) . The air flow now is passive , also the air flows towards the trachea and hence away from the chest wall and our stethoscope …it sounds like the air is receding from the stethoscope …so the last part of expiration in a normal individual is not heard . Actually , the ratio of inspiration to expiration is about 2:3 … We hear it as about 3:2 or 3:1 because of this phenomenon . So a normal vesicular breath sound indicates normal air flow from trachea to alveoli and back .. Please practice this on yourselves a. First with quiet breathing . Appreciate how soft quiet breathing can be . b. Then with forced breathing. c. Compare either side of the chest . d. Compare apex with base . e. Compare the anterior chest wall ( easier to hear) with the posterior chest wall ( more difficult ) f. Vary the amount of pressure with which you apply your stethoscope and note how pressure improves the sound g. Please follow each breath cycle from start to finish with care .
BRONCHIAL BREATH SOUNDS When describing these compare them with vesicular sounds
They are high pitched .
There is an obvious gap between the end of inspiration and the beginning of expiration . 3. The inspiratory phase and the expiratory phase are of equal length . They maybe normal or abnormal . First let us discuss their production . We have discussed air flow just above . A. They can heard normally over large airways . Here , the flowing air is producing a sound which contains both high pitched and low pitched components and the alveoli obviously haven’t filtered the high pitched part away yet . So bronchial breath sounds can be heard normally wherever we can reach large airways with out too much intervening lung parenchyma ( alveoli ) . a. Over the trachea itself b. On either side of the manubrium sterni and the body of the sternum upto the second intercostal space anteriorly . c. Posteriorly , paraspinally , upto vertebrae T4 . Areas b and c are where the trachea bifurcate into the two major bronchi ,right and left . It is clear why the sound is high pitched . The areas have been explained . Now air flows as described above and we hear with the stethoscope placed over the aforementioned areas . We hear air flowing through the airways in the initial part or middle of inspiration ( over the trachea or major bronchi ) and in the similarly during expiration . We do not hear the end inspiration or early expiration which occurs over the alveoli and is not picked because we are auscultating over the centre . So bronchial sounds have an inspiration and expiration of equal length with a gap between them and are high pitched . We shall start all abnormal sounds tomorrow including how abnormal bronchial breath sounds are produced . Bye for now EXAMINATION OF THE RESPIRATORY SYSTEM AUSCULTATION : FINDINGS CONTINUED
Abnormal bronchial breath sounds . Bronchial breath sounds heard anywhere else over the chest are almost always abnormal . This is based on yesterday’s discussion of how breath sounds are produced . Now consider the presence of a consolidation . A consolidation essentially means that the alveoli are fully of exudate due to an infection . This could affect an entire lobe of one lung when we call it lobar consolidation / pneumonia or it could be scattered over one or both lungs in an irregular manner , called bronchopneumonia . In either case ,if the area of consolidation is of sufficient size and is contact with the chest wall too it shall cause a bronchial breath sound . The vital point here is that solid media conduct sound really well , much better than liquid or gas . Also , here the conducting zone of the lung in a particular area , alveoli and all are filled with exudate , in a way , solidified . So they cannot filter out the high pitched components of sound like they normally do .Instead the solid media conducts the high pitched bronchial sound directly to the chest wall and we hear a high- pitched bronchial breath sound . This is the most common type of abnormal bronchial breath sound . Bronchial breath sounds can also be low pitched . This can be seen : a. Lung collapse ( partial) b. Cavity 😊😊 a. Lung collapse We are referring to the absorption collapse mentioned previously . But only when there is partial obstruction to a major bronchus so that a small amount of air may enter . In this case , air flowing through the bronchus enters not the usual alveoli which produce the normal vesicular breath sound but into a cavity ( several causes eg Tuberculosis ) which filters the sounds differently , producing a low -pitched bronchial breath sound . b. Cavity A cavity of a certain size , usually produced by tuberculosis also filters the sound from a bronchus in a similar way to produce a low pitched sound .This is often called a cavernous sound and is a bit difficult to hear . Thus abnormal bronchial sounds can be tubular or low pitched . There is s third type called amphoric . This is also produced by a cavity but one with a particular shape .It must be sufficiently large ,thin walled , and have a narrow entrance , much like an ‘ amphora ‘. ADVENTITIOUS SOUNDS Let us come to three more abnormal sounds a. Crepitations / Crackles b. Rhonchi c. Rub ( eg Pleural Rub) There sounds are together known as adventitious sounds because they are not produced normally .
Crepitations The new term is Crackles . The old term , still acceptable though , is Crepitations . They are produced in two ways chiefly : a. By airflow through the secretions pent up in the alveoli and airways , whatever the cause . b. By sudden forceful opening of closed small airways . These are also described as discontinuous adventitious sounds . Obviously ,air flow through Floyd shall produce a bubbling sound . Also when small airways are closed by an diffuse lung pathology , say fibrosis due to say ILD , forceful breathing often forces the airways open , each opening with a small explosive sound , the summation of these makes the crepitation . We can describe or classify them in several ways : a. By pitch
Coarse
Fine b. By timing
Inspiratory Early or Late
Expiratory Coarse crepitations are often caused by airflow through fluid eg in Bronchiectasis , Bronchitis , Pneumonia in resolution , Pulmonary Oedema due to various causes including heart failure . Fine crepitations are usually caused by ILD and by Pulmonary Oedema , but in an earlier stage when the amount of fluid is less . Classification by timing is far more acceptable nowadays : Early Inspiratory crepitations are caused by Bronchiectasis , Bronchitis , .. Note these cause secretions in the airways , so the sound occurs early when flowing through the larger airways , much before they reach the alveoli . Late inspiratory crepitations would be caused by alveolar involvement eg .. Pulmonary Oedema due to Heart failure or ARDS , ILD . Expiratory crepitations are also caused by Bronchiectasis but sometimes also by Bronchitis . Please read these different types of crepitations carefully .
Rhonchi These are continuous in nature compared to the crepitations . They are musical , whistling sounds produced by turbulent airflow through narrowed airways . They may be monophonic or polyphonic. Monophonic Rhonchi These are uncommon and are produced by partial obstruction of a single airway , say due to a bronchogenic carcinoma . Polyphonic rhonchi This is due to involvement of most airways in a diffuse manner .This is the most common type and is caused by various airway diseases : Bronchitis , Acute and Chronic Asthma Anaphylaxis Pleural Rub This is a rubbing , rough , superficial sound heard due to pleural inflammation . It is the friction between the two pleural surfaces that causes this finding . It is usually heard in inspiration and expiration . It is heard better by pressing the stethoscope firmly to increase the friction created . Often , it has a leathery character . It must be differentiated from crepitations at times .
