Respiratory Exam

Anatomy – surface landmarks

  • Ribs 1-7 articulate with sternum
  • Ribs 8-10 articulate with cartilage above
  • Oblique fissure: from 6th rib at midclavicular line to 5th rib midaxillary line, to spinous process of T3 (RLL below ROF; LLL below LOF)
  • Horizontal fissure: from 4th rib at sternal border to 5th rib midaxillary line on right
  • Lung margins
    • Superiorly 3-4 cm above medial end of clavicles
    • Inferiorly to 6th rib mid clavicular line, 8th rib midaxillary line, between T9-12 posteriorly
  • Bifurcation at T4, sternal angle of Louis
  • RHD end exp at 5th rib anteriorly, T9 posteriorly (slightly higher than LHD)

General

  • Vitals (respiratory rate and pattern)
    • Kussmaul’s – fast and deep breathing (metabolic acidosis)
    • Cheyne-Stokes – irregular with periods of apnea (Rx induced depression, CHF, brain damage)
    • Apnea (cardiac arrest)
  • Assess for distress
    • Facial expression: nasal flaring, pursed lip breathing, audible breath sounds, cyanosis
    • Posture: tripoding, clasp sides of bed (latissimus dorsi), orthopnea
    • Neck: accessory muscle use, tracheal tug
    • Speaking? In sentences?



 

Inspection

  • Configuration of chest: AP diameter, barrel chest, flail chest (paradoxical inward movement during inspiration), kyphoscoliosis, pectus excavatum (depression of sternum), pectus carinatum (protrusion of sternum), body habitus (obese – sleep apnea)
  • Hands: clubbing (intrathoracic tumors, V-A shunts, chronic pulmonary disease, chronic hepatic fibrosis), nicotine stains, splinter hemorrhages (vasculitis), RA associated with pleural effusions and pulmonary fibrosis
  • Cyanosis: central (under the tongue, frenulum, lips), peripheral (fingers, toes, nose)
  • Laryngeal height – sternal notch to thyroid cartilage > 4cm is normal, if less than hyperinflation

Palpation

  • Areas of tenderness
  • Posterior chest excursion (@ level of 10th rib, pulling skin toward midline) – note symmetry
  • Tactile fremitus (ulnar side of hand against chest wall – “ninety-nine”; increased in consolidations, decreased in pneumothorax, effusions, atelectasis)
  • Trachea (midline)
  • Accessory muscles

Percussion

  • Posterior chest
    • Air containing tissue: resonant
    • Air-filled structure: tympanic
    • Consolidation: dull
    • Over-inflation of lungs: hyper-resonance
  • Diaphragmatic Movement
    • Hold deep breath, percuss lowest area of resonance
    • Exhale, repeat percussion
    • Normally 4-5 cm

Auscultation

  • Breathe through mouth
  • Length of inspiration
  • Length of expiration – prolonged in COPD
  • Volume (quiet = distant)

Normal breath sounds

  • Tracheal – very loud, high pitch, insp=exp, harsh, extrathoracic trachea
  • Bronchial – loud, high pitch, insp<exp, tubular, manubrium
  • Bronchovesicular – moderate, moderate pitch, insp=exp, rustling but tubular, mianstem bronchi
  • Vesicular – soft, low pitch, insp>exp, gentle rustling, peripheral lung
  • Stridor – extrathoracic due to blockage in throat or larynx
    • High-pitched musical
    • Inspiratory
  • Crackle (aka rale, crepitation) – excess airway secretions, opening and closing of collapsed distal airways and alveoli
    • Short, discontinuous, nonmusical
    • Mostly during inspiration
    • Bronchitis, Infections, Edema, Atelectasis, Fibrosis, CHF
  • Wheeze (rapid airflow through obstructed airway)
    • Continuous, musical, high pitched
    • Mostly during expiration
    • Asthma, Edema, Bronchitis, CHF
  • Rhonchus (transient airway plugging)
    • Lower-pitched, more sonorous
    • Bronchitis
  • Pleural rub (inflammation of pleura)
    • Grating
    • End of inspiration, beginning of expiration
    • Pneumonia, Pulmonary infarction

Anterior chest

Palpation

  • Tracheal position (feel in suprasternal notch)
  • Tracheal mobility (tracheal tug – support neck, fingers in cricothyroid space with palm facing up, move 1-2 cm) – if fixed, TB or neoplasm
  • Tactile fremitus

Percussion

  • Supraclavicular fossa
  • Axillae
  • Dullness in 3-5th interspaces to left of sternum due to heart

Auscultate

  • Supraclavicular fossa
  • Axillae

Special Tests

  • Egophony (“eeee” will be heard as “aaaa” over areas of consolidation)
  • Whispered pectoriloquy (whisper “1-2-3”, normally nothing heard, but transmission increased if consolidation)
  • Bronchophony (say “ninety-nine”, heard louder over consolidation)

Clinical correlates

Consolidation:

  • Dullness
  • Crackles
  • Increased breath sounds
  • Increased tactile fremitus

Pleural Effusion

  • Dullness
  • Decreased breath sounds
  • Decreased tactile fremitus

COPD

  • Impaired breath sounds
  • Barrel chest
  • Decreased chest expansion
  • Impaired cardiac dullness
  • Use of accessory muscles
  • Absent cardiac impulse
  • Cyanosis
  • ↓ diaphragmatic excursion

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