Description #

This unit is intended to introduce the undergraduate medical students to common symptoms of respiratory diseases.

Learning Objectives #

At the end of this unit, students should be able to:

List the key symptoms of respiratory diseases

Respiratory Symptoms #

The key symptoms of respiratory disease include:

• shortness of breath or dyspnea
• cough (which may be productive of sputum or non-productive)
• cough with hemoptysis or blood-streaked sputum
• wheezing
• chest pain

It is important to note whether the pain is pleuritic (worsens with inspiration) or non-pleuritic (has no relationship to respiration). Commonly, there may be accompanying symptoms of upper respiratory tract conditions such as runny nose, postnasal drip, hoarseness, snoring, sore throat, plugged ears, painful ears, and sinus pain.

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Anatomy of the Thorax #

Basic Anatomy #

In the following video, you should note the location of the:

• sternum
• lungs
• heart
• diaphragm
• trachea
• scapulae

Landmarks #

It is also useful to review the following basic anatomic landmarks:

• clavicle
• suprasternal notch is the visible and palpable depression at the base of the neck that is flanked by the heads of the clavicles
• manubrium
• manubrio-sternal junction or Angle of Louis is visible and palpable where the manubrium and body of the sternum connect at the level of the 2nd rib. As the first rib is under the clavicle, the ribs and intercostal spaces are counted from this angle
• body of sternum
• xiphoid process
• costal angle is formed at the junction of costal margins at the sternum. Normally it is about 90 degrees which means that each costal margin is connected to the sternum at 45 degrees.
• nipples
• vertebra prominens is the spinous process of C7. It is more palpable and visible when the head of the patient is bent forward. Below this point is T1. The spinous process of T1 to T4 can be palpated. Below T4, the process is projected obliquely and cannot be palpated.

Surface Anatomy #

In conjunction with the anatomic landmarks of the chest, the following imaginary lines on the surface will help localize the findings on the physical examination:

• midsternal line extends vertically down the mid-line of the sternum
• right and left midclavicular lines is parallel to the midsternal line, beginning at the mid-clavicle. The inferior borders of the lung generally cross the sixth rib at the midclavicular line.
• right and left anterior axillary lines is parallel to the midsternal line, beginning at the anterior axillary folds.
• right and left midaxillary lines is parallel to the midsternal line, beginning at the midaxilla.
• right and left posterior axillary lines is parallel to the midsternal line, beginning at the posterior axillary folds.
• vertebral line lies vertically down the spinal processes.
• right and left scapular lines is parallel to the vertebral line, through the inferior angle of the scapula, when the patient is erect.

Also note the following locations on the thorax:

• supraclavicular region is the area above the clavicle
• infraclavicular region is the area below the clavicle
• interscapular region is the area between the scapulae
• infrascapular region is the area below the scapula
• base of lungs
• apices of lungs

Lung Fissures and Lobes #

We will now take a more detailed look at the bronchial tree, lungs and pleura.

Bronchial Tree #

   The airways of the respiratory system include the nasal passages and nasopharynx, the mouth and oropharynx, the larynx, the trachea and the branches of the bronchial tree. The trachea bifurcates asymmetrically into the right and left bronchus at the level of the sternal angle anteriorly and the T4 spinous process posteriorly. The dividing septum is called the carina. The right bronchus deviates slightly from the axis of the trachea, but the left diverges at a greater angle. The clinical significance of this is the increased possibility of the inadvertant intubation of the right mainstream bronchus in the OR or ICU. Superiorly is the larynx. The heart lies in front of the tracheal bifurcation and the aorta arches over the left bronchus from front to back.

   Interposed between the aorta and the left bronchus is the left recurrent laryngeal nerve, which descends in front of the aortic arch, loops under it and ascends beside the trachea to the neck. Its long course makes it vulnerable to injury with consequent paralysis of the left vocal cord.

Lungs #

     Anteriorly, the apices of the lungs rise about 2-4 cm above the inner third of the clavicle. The lower border crosses the 6th rib at the midcalvicular line and the 8thrib at the mid-axillary line. Posteriorly, the lower border of the lung lies at about the level of the T10 spinous process. The shape of both lungs is similar and is moulded by the contour of the thoracic cavity. The medial edge of the left lung has an inferior indentation, called the cardiac notch.

     The lungs are subdivided into lobes by lobar fissures, which are formed by infolding of the visceral pleura. In the left lung, the major or oblique fissure projects from T3 spinous process down to the 6th rib at the mid-clavicular line. The oblique fissure roughly divides the left lung into two equal lobes: the upper and lower lobes, each of which is supplied by a lobar bronchus. Similarily, in the right lung the oblique fissure defines the lower lobe posteriorly. Anteriorly, the right lung is further subdivided into the right middle lobe and the right upper lobe, by the horizontal or minor fissure, which projects close to the 4th rib and meets the oblique fissure in the mid-axillary line.     

     The topography of the 5 lung lobes has some clinical applications and are, therefore, important for us to note. The anterior aspect of the right lung is formed almost entirely of the right upper and middle lobes; the posterior aspect contains only the upper and lower lobes. In the left lung, the upper and lower lobes are present at both the back and front. This understanding of the topography helps identify what parts of the lungs are affected by an abnormal process. For example, abnormal signs in the right upper chest are likely due to a disease process in the right upper lobe. On the other hand, abnormal signs in the lateral right mid-chest may originate from any of the three right lobes.

Pleura #

     Pleurae are serous membranes that allow the lung some mobility with the thoracic cavity. The outermost layer, the parietal pleura is adherent to the thoracic wall. The parietal pleura has the greater area, lining the inner rib cage and upper surfaces of the diaphragm. The visceral pleura covers the outer surface of each lung, and also lines the interlobar fissures. It is fixed to the lung surface. The parietal pleura also extends inferiorly some distance below the lower tip of the lung to form the costophrenic sinus. The lung descends into this sinus during deep inspiration. The two apposing layers, the visceral pleura, and the parietal pleurae, form the pleural cavity. It is a virtual cavity that is devoid of air, but contains enough fluid for lubrication to allow the lungs to move easily within the rib cage during respiration.

Mechanics Of Breathing #

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Respiratory Excursion of the Thorax #

     The first rib and sternum are fixed by the scaleni while contraction of the external and internal intercostals muscles narrow the intercostals spaces. The ribs are thus pulled upwards and the sternum thrust forward, increasing the anterior-posterior dimension of the thoracic cavity. Similarly, fixation of the first rib and sternum by the scaleni and narrowing of the intercostal muscles cause rotation of each rib, except the first, on both an anterior-posterior and transverse axis, expanding the corresponding dimensions of the thoracic cavity. Since the lower ribs are longer and more oblique, and the interspaces are wider, the amplitude of movement is greater in the lower thorax.

     The diaphragm is an elliptic sheet of muscle whose centre is a fibrous aponeurosis. The edges of the sheet are fixed to the lower ribs while the centre forms a dome into the cavity. After expiration, the dome is high and the thoracic walls are closest together. During inspiration, the walls diverge, lowering the diaphragmatic dome. The dome is further flattened by contraction of the diaphragmatic muscle during inspiration. Lowering the diaphragm elongates the vertical dimension of the thoracic cavity to increase its volume.

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Clinical Examination: Breathing Patterns #

Clinical Examination #

     The clinical exam begins the moment you enter the room and look at the patient from a distance. You can note the patient’s gender, approximate age, level of consciousness, degree of illness (and whether it is acute or chronic), any evident discomfort, and their position in the examining bed. You will also be able to assess the body habitus, noting if the patient is of average weight, overweight or underweight. Once this preliminary assessment is completed, you should observe respiratory patterns, noting the rate, depth, regularity and effort of the patient’s breathing. Normal breathing should not be heard farther than 1 meter from a patient who is at rest.

     The usual respiratory rate is 12 to 20 breaths per minute in the adult, and it is regular and effortless. In the newborn, the rate is about 44 breaths per minute. To assess the respiratory rate, you may observe the rise and fall of the abdomen, since at rest diaphragmatic movement accounts for about 75% of the tidal volume. Alternatively, you may watch the chest rise and fall. Don’t tell the patient what you are doing or they may abnormally alter the respiratory rate. Count the number of breaths the patient take in 30 seconds and multiply by 2 to get the respiratory rate. Abnormal breathing patterns denote an underlying respiratory or other medical problem. 

Breathing Patterns #

Abnormal breathing patterns denote an underlying respiratory or other medical problem.

Some abnormal breathing patterns to note include:

• tachypnea
• hyperpnea
• bradypnea 
• Kussmaul respiration
• Cheyne-Stokes respiration 
• Biot’s or ataxic breathing 
• sighing respiration 
• obstructive breathing
• laboured breathing

Additionally, before beginning the respiratory examination, you should check the other vital signs:

Blood pressure, Heart rate, Temperature, and Oxygen saturation.

Tachypnea, Hyperpnea & Bradypnea #

• tachypnea or fast, shallow breathing. This can occur with exertion, fever, cardiac insufficiency, pain, acute respiratory distress from infections, pleurisy, anemia and thyrotoxicosis.
• hyperpnea refers to fast deep breathing. It has several causes including exercise, anxiety, and metabolic acidosis. In comatose patients, hyperpnea may be due to infarction, hypoxia or hypoglycemia affecting the midbrain or pons.
• bradypnea or slow breathing refers to when the rate is slow and the is rhythm regular. Breathing is usually deeper than normal. Breathing rate can be slowed as a result of uremia, diabetic coma, excessive alcohol or morphine consumption, and conditions with increased intracranial pressure.
• Kussmaul respiration refers to deep, regular breathing whether the rate be normal, slow or fast. This occurs in diabetic acidosis and uremia.

Cheyne-Stokes & Biot’s Respiration #

• Cheyne-Stokes respiration is the commonest form of periodic breathing. Periods of apnea alternate regularly with a series of respiratory cycles. In each series, the rate and amplitude of successive cycles increase to a maximum. Then there is a progressive diminution until the series is terminated by another period of apnea. Period breathing may occur normally during sleep in children and the aged. Vascular causes include disorders of the cerebral circulation from heart failure, lesions of the aortic valve, low diastolic pressure, thyrotoxicosis, dissecting aneurysm and patent ductus arteriosus. It may also be caused by increased intracranial pressure from meningitis, hydrocephalus, tumour, subarachnoid hemorrhage, and intracranial bleed, as well as injury to the brain tissue from cerebral thrombosis, head injury or atherosclerosis. Narcotics, such as morphine and its derivatives, can also result in period breathing.
• Biot’s or ataxic breathing is an uncommon variant of Cheynes-Stokes respiration in which periods of apnea alternate irregularly with a series of breaths that stop abruptly for short periods. The breaths may be deep or shallow. It is most common in meningitis, but can be observed in respiratory depression or any condition that damages the medulla of the brain.

Sighing, Obstructive & Laboured Breathing #

• sighing respiration refers to a normal breathing pattern occasionally interrupted by a long deep sigh. It may be indicative of hyperventilation syndrome. Occasional sighs are normal.
• obstructive breathing occurs in asthma, chronic bronchitis and chronic obstructive pulmonary disease. The expiratory phase is prolonged due to narrowing of the airways.
• laboured breathing occurs when there is inspiratory retraction of the supraclavicular areas, and inspiratory contraction of the accessory muscles of respiration, especially the sternocleidomastoids.

Stridor & Wheeze #

Next, note the quality of the patient’s voice and whether he or she is hoarse. As well, you can determine if stridor or wheezing is present. 

• stridor is caused by obstruction in the upper airway from a foreign body or epiglottis. It occurs during inspiration. This is a serious condition that requires urgent attention
• audible wheezing occurs during expiration and is observed in asthma and COPD, Chronic Obstructive Pulmonary Disease.

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Clinical Examination: Extrapulmonary #

The full respiratory examination can be divided into two parts: extra-pulmonary and pulmonary examinations.

There are a few important extra-pulmonary findings that must be looked for: 

• pallor
• cyanosis
• peripheral edema
• clubbing of fingers
• trachea
• accessory muscle use
• lymph nodes

Pallor & Cyanosis #

• pallor is due to a low haemoglobin may be evident on the skin or on the conjunctivae, the oral mucosa, or palmar creases.
• cyanosis refers to a bluish coloured skin. It may be central or peripheral. Central cyanosis can be best detected by looking at the tongue. It is also evident on the lips and face. Central cyanosis is the result of low oxygen in the blood. Hemoglobin saturated with oxygen is red. As it deoxygenates, it becomes darker. There must be 5 grams per decalitre of deoxygenated haemoglobin present to see cyanosis. Peripheral cyanosis may be normal, and related to constriction of vessels in the extremities, for example, in the cold. It can be associated with central cyanosis.

Peripheral Edema & Clubbing #

• peripheral edema can be seen on the walking patient’s feet and ankles, or over the posterior calves or sacrum of the bedridden patient. Note that unilateral leg edema may be a sign of a deep vein thrombosis.
• clubbing of fingers is seen in situations where the patient is chronically hypoxemic, but can also develop with normal oxygen levels. It commonly develops with cyanotic congenital heart disease, lung cancer, lung abscess, and cystic fibrosis. Rarely, there are also gastrointestinal causes. Clubbing is painless and usually bilateral. The thumb and index fingers are usually the first involved; later the other fingers and toes are involved. The first sign of clubbing is a sponginess of the proximal nail bed, which can be appreciated by pressing the mantle with the tip of your finger with pressure the plate sinks towards the bone – with release of pressure, the plate springs away from the bone. Next, the angle between the plate and proximal nail fold increases to 180º or more, leading to a loss of the normal space loss of between the apposed digits. Later, there is increased curving of the fingernails. In advanced cases of clubbing, the dorsal phalanx becomes rounded and bulbous.

Trachea #

• trachea is normally found in the midline, but in older people it may be shifted slightly to the right. It may be pushed away to the opposite side by a large pneumothorax or pleural effusion, or drawn towards the side of extensive atelectasis. Thyroid enlargement may shift it either way. The trachea is best examined with the patient’s head in mild flexion. Assess the position of the trachea by palpating its relationship to the sternomastoid muscle. Place the forefinger along one side of the trachea and feel the size of the space between it and the sternomastoid muscle; next, compare this space with that on the other side. The spaces should be equal if the trachea is in the midline. An alternative method is to direct two fingers through the suprasternal notch until they touch the tracheal rings, comparing the distance from the lateral tracheal wall to the head of the clavicles.

Accessory Muscles of Respiration #

• accessory muscles of respiration are normally not used unless the patient is very short of breath. There is inspiratory retraction of the supraclavicular areas, and inspiratory contraction of the accessory muscles of respiration, especially the sternocleidomastoids. It is possible to palpate the contraction of these muscles before it it visible on inspection. Use of the accessory muscles indicates severe obstructive lung disease and correlates with an FEV 1 less than 30%.

Lymph Nodes #

• lymph nodes are present in 4 groups in the neck. Palpate the occipital nodes, pre- and post-auricular nodes, sub-mandibular nodes, anterior and posterior cervical nodes. Soft, tender, mobile nodes are usually associated with infection whereas firm/hard, ‘matted down’ nodes may signify a malignancy. Note that it is not uncommon to palpate small mobile nodes, measuring a few millimetres, in the cervical region in normal persons. Palplable nodes in the supraclavicular area are almost always an abnormal finding, and are usually due to metastasis from a lung cancer. Cancers of the GI tract may also metastasize to the medial left supraclavicular node, called Virchow’s node. This node may be small and deep to the head of the clavicle. While supraclavicular nodes can be involved in pulmonary disease, it is important to note that the hilar and mediastinal nodes are the first to be affected. These can only be assessed by imaging studies.

Ears, Nose & Throat #

     As we have already mentioned, the patient’s presenting complaint often involves upper and lower respiratory symptoms (ear pain, coryza, sinus pain, sore throat as well as cough). In these situations, the extra-pulmonary examination will include the above, as well as examination of some of the parts of the head and neck examination. This includes an examination of the ears, nose, sinuses and mouth and throat

Ears #

• ears – examine the auricle of the ear, and check behind the ear for nodes. Check the lobule and helix for infected piercings from earrings. Use the otoscope to examine the auditory canal, noting wax or other foreign bodies; redness or edema of otitis externa; and assess the tympanic membrane for perforations, redness, and bulging.

Nose & Sinuses #

• nose – examine the nose, looking for foreign bodies, and assessing the health of the mucosa (redness, swelling, bleeding/scabbing of Little’s area). Assess for deviation of the septum.
• sinuses – with your thumbs, press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary and ethmoid sinuses. Localized tenderness in these areas indicate acute sinusitis.

Throat & Mouth #

• throat and mouth – examine the teeth, gingiva, tongue and pharynx. Note the presence or absence of tonsils. Many patients over 30 will have had tonsillectomies as children. Most children and young adults you examine will have their tonsils. Look for large tonsils, redness, and pus.

Clinical Examination – Pulmonary: Posterior Chest #

Examination of the Posterior Chest #

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Inspection #

    It is convenient to examine first the posterior chest and then the anterior chest. We have already noted some of the important findings on inspection.  For example, cyanosis, dyspnea, and use of accessory muscles have been mentioned. In addition, observe for the presence of deformities, such as:

• kyphosis is an increase in the normal thoracic convexity
• scoliosis is a lateral curvature of spine
• kyphoscoliosis is a combination of kyphosis and scoliosis

    Also note the anterior-posterior diameter or AP diameter. In severe obstructive lung disease, this is increased. Inspect the chest for abnormal inspiratory retraction of the interspaces that may occur with airway obstruction. And inspect for impairment or unilateral lag in respiratory movement due to disease of the underlying lung or pleura or phrenic nerve palsy.

Palpation #

    The second component of the respiratory examination of the posterior chest is palpation. Palpate the chest wall and feel for abnormalities, such as masses or sinus tracts, and check for any tenderness in the ribs and cartilage due to trauma or fractures.

Chest Wall Excursion #

    Next, check the Chest wall excursion by ensuring that with inspiration, the chest expands. The lower lobe excursion is by lateral movement of the chest wall while the upper and middle lobes move anteriorly. Normally, the excursion is symmetric. In COPD and restrictive lung diseases, there is impairment of expansion of both sides of the chest. In certain conditions affecting the chest wall, pleura or lung, there is diminished local excursion of the chest and the affected area may begin to move later and move less than the normal one.

Assessing Chest Wall Excursion:

• place your palms on the posterio-lateral chest at about the level of the 10th rib with the fingers loosely grasping and parallel to the lateral rib cage
• slide your hands medially to raise a loose fold of skin on each side between your thumb and the spine
• ask the patient to take a deep breath and watch the movement of your thumbs during inspiration
• note the range, timing and symmetry of the rib cage as it expands and contracts

    A unilateral lag indicates chronic fibrotic disease of the lung or pleura, pleural effusion, lobar pneumonia, bronchial obstruction, or splinting due to a painful lesion in the chest wall or pleura.

Modified Hoover’s Sign #

    Normally, with deep inspiration, the lateral ribs flare and the costal margin widens. If the lungs are over-inflated, accompanied with a low flat diaphragm, the lateral chest wall may be drawn inwards with inspiration. Also evident is a reduction of the costal angle. This phenomena is very commonly seen in patients with severe COPD, and is called the modified Hoover’s sign.

Tactile Fremitus #

    Tactile fremitus arises from vibrations from the patient’s voice. It can be perceived by your hand on the patient’s chest. You may use the bony part on the palmar bases of your fingers, or the ulnar border of your hand, to feel these vibrations. In checking for fremitus, place your hand in the interspaces and ask the patient to say “99” or “1, 2, 3”. You will feel the vibrations. However, if fremitus is faint, ask the patient to speak more loudly or in a deeper voice. Symmetric points on the chest are palpated sequentially, and the strength of the fremitus is assessed. When the lower chest is reached, use the ulnar surface of the hand in the interspaces to ascertain the level at which fremitus is lost. In the absence of any pleural disease, this should be the position of the lung bases. Check for fremitus at the following sites:

• in the upper one third of the chest, assessing the upper lobes
• in the middle one third, assessing the superior segment of the lower lobes
• in the lower one third, assessing the basal segments of the lower lobes check for fremitus medial to mid scapular line, and lateral to mid scapular line

    It is important to compare both sides, using the same hand. The palpable vibrations of the chest come from movements of the broncho-tracheal air column. Failure of the vocal cords or blockage of the airways results in absent vocal fremitus. It is decreased or absent in atelectasis, as well as in the presence of pneumothorax or pleural effusion, which filters the transmission of the vibrations. Tactile fremitus is increased in those disorders where the lung is more dense, such as the consolidation of pneumonia or inflammation around a lung abscess. The air vibrations are transmitted with greater efficiency in these conditions than the air-filled pulmonary alveoli; hence, fremitus is increased.

Percussion #

The third component of the respiratory examination of the posterior chest is percussion.

Percussion Technique:

• with the patient sitting up, press the middle finger or “pleximeter finger” of your left hand (assuming you are right handed) firmly into the interspaces on the chest wall of the patient
• the percussing finger, the “plexor” is the middle finger of the right hand and is partly flexed and rigid
• percussion should be over the pre- terminal digit, not the joint
• percussion should be a wrist motion entirely, and neither the elbow nor shoulder should move
• the excursion of the plexor should be 7-9 cm
• when percussing posteriorly, it is helpful to have the patient cross his arms across the anterior chest.
• Percuss about 3 times at each site, following this pattern, comparing the two sides.

Percussion Notes #

There are three types of percussion notes:

• Normal resonance is heard over a normal lung
• Dull sounds are heard over an area of consolidation or atelectasis. The percussion note over plural effusion has a flat or stony quality.
• Hyper-resonance is a hollow sound that typically occurs over a large pneumothorax (as over the stomach bubble)

Assessment of Diaphragmatic Excursion #

    Diaphragmatic excursion cam be assessed by percussion of the diaphragmatic level with respiration. The diaphragm is generally about the level of the 9th posterior rib, in the mid scapular line. It may normally be 1-2 cm higher on the right.

• find the resting level of the diaphragm by percussing from top to bottom as shown here. The resting level of the diaphragm is the point where the percussion note changes from resonant to dull.
• next, assess diaphragmatic excursion by comparing the position in maximum expiration, and maximum inspiration. 
• normal excursion is 5-7 cm.
• this manoeuver should be done on both sides of the midline, since, as mentioned, the diaphragm is 1 to 2 cm. higher on the right.

    You will not do this manoeuvre in a routine examination of the respiratory system, unless you suspect diaphragmatic weakness. It is important to note that a pleural effusion raises the level of dullness.

Auscultation #

    The fourth component of the respiratory examination of the posterior chest is auscultation. In the examination of the chest, the stethoscope is used to hear the breath sounds and listen for adventitious or extra sounds. Ensure that the stethoscope is not cold by keeping it in your pocket or holding it in your hand for 2 or 3 minutes while talking to the patient. For the lungs, the diaphragm head of the stethoscope is best because of the pitch of breath sounds and adventitious sounds.

• ask the patient to take deep breaths with the mouth open
• listen and compare equivalent sites over each lung in the “ladder” pattern. For example, left upper lung, then right upper lung etc.
• listen at the same areas described for tactile fremitus and percussion
• listen for the presence and the type of breath sounds and the presence of adventitious sounds
• note breath sounds are usually louder in the upper anterior lung fields

Types of Breath Sounds #

Ausculation may reveal the following breath sounds:

• normal or vesicular
• bronchial
• tracheal
• bronchovesicular

Normal or Vesicular Breath Sounds #

   Normal or Vesicular breath sounds occur in shallow breathing during quiet respiration producing a “whishing” sound that can be heard over the surface of the lungs. The inspiratory phase is long, being about 3 times the expiratory phase. The sounds have a medium pitch. Vesicular breath sounds are heard normally over the entire lung surface, except beneath the manubrium and the upper interscapular region, where they are replaced by bronchvesicular sounds. It is abnormal if these sounds are not present.

Bronchial Breath Sounds #

    Bronchial breath sounds have a shorter inspiratory phase and a longer expiratory phase as compared to vesicular breathing. There is a gap between inspiration and expiration. They are high pitched and loud. Bronchial breath sounds do not occur in the normal lung. Bronchial breath sounds are heard over consolidation, such as in pneumonia, or compression of lung tissue. Consolidation facilitates transmission of sound from the bronchial tree. If bronchial breath sounds are audible in abnormal places, suggesting a consolidation, you should assess transmitted voice sounds, which we will discuss shortly.

Tracheal Breath Sounds #

    Tracheal breath sounds are the closest normal counterpart to bronchial breath sounds and are heard in the suprasternal notch and over the 6th and 7th cervical spines. Tracheal breath sounds have no pathological significance.

Bronchovesicular Breath Sounds #

    Bronchovesicular breath sounds are intermediate between vesicular and bronchial breath sounds. The two respiratory phases are about equal in duration, although the expiratory phase may be a bit longer. Normally, it is heard at the manubrium and in the upper interscapular region. In other parts of the lung, bronchovesicular breath sounds are pathological and indicate a small degree of consolidation or compression that transmits sounds from the bronchial tree. As the degree of compression or consolidation increases, bronchovesicular breath sounds are converted to bronchial breath sounds.

Voice Sounds #

    Whispered and spoken sounds can be valuable in detecting pulmonary consolidation, infarction and atelectasis because of their pitch and loudness. In the normal lungs, whispered words are faint and the syllables are not distinct, except over the main bronchi. Increases in loudness and distinctness have pathological significance.

Whispered Pectoriloquy #

    Normally, whispered words are transmitted faintly and indistinctly through normal air-filled lungs. Pulmonary consolidation transmits whispered syllables distinctly even when the pathological process is too small to produce bronchial breathing. This is useful in detecting early pneumonia, infarction or atelectasis. This can elicited by asking the patient to say “99” or “1,2,3”.

Bronchophony #

    Normally, the spoken syllables are indistinctly heard in the lungs. In the presence of pulmonary consolidation, syllables are heard distinctly and sound very close to the ear. The sign can be elicited by asking the patient to say “99” or “ee”.

Egophony #

    In the normal lung, a spoken “ee” is heard as “ee”. Egophony is a form of bronchophony in which the spoken syllables have a peculiar nasal or bleating quality – “ee” is heard as “ay”. It is heard in pulmonary consolidation or may be due to compressed lung above a pleural effusion.

Adventitious Sounds #

This section of the module will cover the following adventitious or abnormal breath sounds:

• Crackles
• Wheeze
• Stridor
• Pleural Rub 

Crackles & Wheezes #

• crackles are due to opening of small airways or secretions within the airways. They are a discontinuous sound, which sounds like velcro coming apart. Inspiratory crackles are heard in the bases of the lungs. Crackles are “fine” in fibrosis of the lung, or in pulmonary edema. In pneumonia or bronchiectasis, the crackles are coarse. Crackles in the apices occur with tuberculosis.
• wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure. They are due to bronchospasm, secretions, airway collapse or obstruction. They can be coarse or fine, and have been described as musical in nature. Wheezes are heard mainly during expiration. Causes of generalized wheezes heard throughout the chest are asthma and bronchitis. In asthma, wheezes may be heard in expiration, or during both inspiration and expiration. In bronchitis, wheezes are due to secretions in the larger airways and may clear with coughing. A localized wheeze suggests a partial obstruction of a bronchus, such a tumor or foreign body. It may be inspiratory, expiratory or both. In the past, and in many texts, you will see the term “rhonchi”. This is now called “coarse wheezes”.

Stridor #

• stridor is wheeze that is entirely or predominantly inspiratory. It is often louder in the neck than over the chest wall. It is caused by a partial obstruction of the larynx or trachea and can indicate an emergency situation.

Pleural Rub #

• pleural rub or pleural friction rub is created by inflammation of the pleura that may result in loss of lubricating fluids causing the pleural surfaces to rub against each other. It sounds like a “squeaky door”. It is present in inspiration and expiration, and may be inconstant, lasting for a few respiratory movements, then disappearing for a while. A rub is usually confined to a relatively small area of the chest wall. Pleural rub is usually associated with pleuritic chest pain. The rub can disappear if a pleural effusion develops. The presence of a rub suggests pleuritis, usually pneumonia or pulmonary infarct.

Clinical Examination – Pulmonary: Anterior Chest #

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Inspection #

Observe for any deformities such as:

• pectus excavatum is a severe retraction of the sternum
• pectus carinatum is an anterior protrusion of the sternum

     Also check for thoracic and or abdominal breathing and ascertain if they are symmetrical and regular. You may also observe a flail chest due to fracture of at least 3 ribs, usually from trauma, in two or more places, leading to a free segment of the thoracic cage. With respiration, there is a paradoxical movement of the injured area. Descent of the diaphragm on inspiration decreases the intra-thoracic pressure. This causes the injured area to cave inward. On expiration, it moves outward, causing a bulge.

Palpation #

     The chest wall is palpated to check for masses, and tenderness in the ribs and cartilage or muscles. In the acutely ill patient in respiratory distress, you can also appreciate the movements of a flail chest on palpation. Furthermore, contraction of the accessory neck muscles may be palpated before it is obvious on inspection

Respiratory Expansion #

• check for respiratory expansion of the upper chest by placing your hands on each side of the patient’s neck with your palms against the upper anterior chest
• extend your thumbs so that they meet close to the midline
• ask the patient to inhale deeply
• keep your fingers anchored above the trapezius muscle while you permit your palms to move freely
• the upper 4 ribs move forward so your thumbs diverge from the midline
• normally, the thumbs move laterally for equal distances. Asymmetric movement indicates disease of the chest wall, pleura or upper lobe of the lung
• excursion of the anterior middle chest is tested by placing your hands in each axilla with the palms lightly against the chest wall and the thumbs meeting in the midline at the level of the 6th rib
• ask the patient to inhale deeply and let your hands follow the chest movements
• the thumbs should diverge bilaterally. A unilateral lag indicates disease of the chest wall, pleura, or right middle lobe of the lingular segment of the left upper lobe

Tactile Fremitus #

• tactile fremitus is checked anteriorly using one of the two methods described earlier, that is, using the palmar bases of your fingers, or the ulnar border of your hand. Check the area between the clavicle and rib margin, and in the axillae.

Percussion #

Percuss the chest as shown, using the same techniques as described previously.

Auscultation #

Auscultate the anterior chest as shown, noting the breath sounds, adventitious sounds and, if indicated, transmitted voice sounds.