SIGNIFICANCE
Clinical examination of the respiratory system is carried out to assess the functional status of the respiratory tract and lungs
GENERAL
EXAMINATION
Before doing the examination of the respiratory system, a general examination relevant to the respiratory system should be carried out.
Appearance
Pallor
Cyanosis
Clubbing (Excessive curvature of the nail)
Venous pulses
Lymph node enlargement
Examination of the respiratory system is carried out by:
- Inspection
- Palpation
- Percussion
- Auscultation
EXAMINATION OF THE CHEST
INSPECTION
- Shape of the chest
The normal chest is bilaterally symmetrical and elliptical in cross section
The transverse diameter – anterioposterior diameter
Common Abnormalities of Shape
Kyphosis – forward bending of vertebral column
Scoliosis – lateral bending of vertebral column
Barrel shaped chest – increase in anteroposterior diameter flattening
INSPECTION
- Rate and Rhythm of respiration
Rate of respiration in health (adult) 12 to 14 breaths/min
- Measurement of chest expansion
Chest expansion can be measured with a tape measure around the chest just below the nipples in a healthy adult it is about 3 to 5 cm
- Symmetry of chest expansion
Chest expansion of a healthy adult should be equal on both sides
- Movements of the chest wall
Presence of intercostals recessions or the use of accessory muscles
PALPATION
Before making a systemic examination palpate any part of the chest where the patient complains of pain or where there is a swelling
- Position of the Apex beat and Trachea
In normal subjects the trachea is in the midline and can be palpated in the suprasternal notch
The apex beat ( the lowest and outermost point of definite cardiac pulsations) can be usually palpated in the 5th intercostals space withing the midclavicular line
Displacement of the apex beat and trachea indicates that the position of the mediastinum has been altered. This may be due to diseases of the heart, lungs or pleura
PALPATION
- Expansion of the chest
Symmetrical or asymmetrical chest expansion can be assessed by palpation
Vocal fremitus
Vocal fremitus is the vibration detected by palpation with the pal of the hand on the chest, when the patient is asked to repeat ‘ninety nine’ or ‘anunavaya’
In a normal healthy adult, the vibrations felt in the corresponding areas on the two sides of the chest are equal in intensity
PERCUSSION
The middle finger of the left hand is placed on the chest and middle phalanx is struck with the tip of the middle finger of the right hand
Compare the percussion note (resonant) with that of the corresponding area on the opposite side of the chest
A resonant sound is produced during percussion. The sound and feel of resonance over a healthy lung has to be learned by practice
AUSCULTATION
- Breathing sounds
There are 2 types of breath sounds (vesicular breath sounds and bronchial breath sounds)
Vesicular breath sounds
These originate in the larger airways and are produced by the passage of air in and out of normal lung tissue
In good health, they can be heard all over the chest
- The inspiration is longer than expiration
- The inspiratory sound is intense and louder than the expiratory sound
- It is a low pitched rustling sound
- There is no gap between inspiration and expiration
Vesicular breathing with prolonged expiration
Example: airway obstruction (asthma)
AUSCULTATION
- Bronchial breath sounds
These are produced by the passage of air in the trachea and larger bronchi
In good health, they can be heard only over the trachea
In disease, bronchial breathing may be heard over the area of lung that is affected (lung collapse, fibrosis or when there is cavity)
- The expiration is long as or longer than inspiration
- The pitch and sound of the expiration is loud or louder than the inspiratory sounds
- There is a gap between inspiration and expiration
AUSCULTATION
- Vocal Resonance
the resonant sound that is heard with the stethoscope when the patient is asked to repeat ‘ninety nine’ or ‘anunavava’
This depends on the loudness and the depth of the patients voice and the conductivity of the lungs
AUSCULTATION
- Added sounds
These are abnormal sounds that arise in the pleura or lungs
Rhonchi – wheezing sound (asthma)
Crepitations – bubbling or crackling noises
Pleural rub – creaking or rubbing noises associated with pain
