2. Examination of Respiratory System
The respiratory system consists of the
oThe lungs
oThe branching airways(trachea & bronchi)
oThe gaseous exchange membrane
oThe rib cages and
oThe respiratory muscle.
The respiratory system consists of the
oThe lungs
oThe branching airways(trachea & bronchi)
oThe gaseous exchange membrane
oThe rib cages and
oThe respiratory muscle.
2
3. Anatomic review
• Thoracic cage is a bony structure Bounded by
Sternum--anteriorly
12 pairs of ribs –anteriorly & poteriorly
12 thoracic vertebrae—posteriorly
Floor
oDiaphragm –
oMusculotendenous septum- separet from
abdomen
• Thoracic cage is a bony structure Bounded by
Sternum--anteriorly
12 pairs of ribs –anteriorly & poteriorly
12 thoracic vertebrae—posteriorly
Floor
oDiaphragm –
oMusculotendenous septum- separet from
abdomen
3
11. Locating Findings on the Chest
Describe abnormalities of the chest in two
dimensions:
along the vertical axis and
around the circumference of the chest.
Describe abnormalities of the chest in two
dimensions:
along the vertical axis and
around the circumference of the chest.
11
12. Locating vertically
Number ribs and interspaces accurately.
Antreriorly, the sternal angle (Angle of Louis),
the horizontal bony ridge that joins the
manibrium to the body, is the best guide.
Moving laterally from the Angle of Louis, you
find the adjacent second rib and costal
cartilage.
Now you can walk down the inter spaces using
your two fingers.
An inter space is named by the rib above it.
Number ribs and interspaces accurately.
Antreriorly, the sternal angle (Angle of Louis),
the horizontal bony ridge that joins the
manibrium to the body, is the best guide.
Moving laterally from the Angle of Louis, you
find the adjacent second rib and costal
cartilage.
Now you can walk down the inter spaces using
your two fingers.
An inter space is named by the rib above it.
12
13. Cont…
Posteriorly, the 12th rib gives an other
possible starting point for counting the ribs
and inter spaces.
This is especially useful in locating findings on
the lower posterior chest and also helps when
the anterior approach is unsatisfactory.
The inferior angle of the scapula lies at the
level of the 7th rib or interspace
Posteriorly, the 12th rib gives an other
possible starting point for counting the ribs
and inter spaces.
This is especially useful in locating findings on
the lower posterior chest and also helps when
the anterior approach is unsatisfactory.
The inferior angle of the scapula lies at the
level of the 7th rib or interspace
13
14. Cont…
The spinous process of the 7th cervical
vertebrae (When a person flexes his neck for
ward, the most prominent process is usually
that of the seventh cervical vertebrae, and
when two processes appear equally
prominent, they are of the seventh cervical
and the first thoracic vertebrae)
Helps to locate findings posteriorly.
The spinous process of the 7th cervical
vertebrae (When a person flexes his neck for
ward, the most prominent process is usually
that of the seventh cervical vertebrae, and
when two processes appear equally
prominent, they are of the seventh cervical
and the first thoracic vertebrae)
Helps to locate findings posteriorly.
14
17. Locating Findings Around The
Circumference of The Chest
• The mid sternal and vertebral lines precise; others
are estimated.
• These lines drop vertically in the middle of the
sternum and the vertebral column respectively.
• The mid clavicular lines –drop vertically from the
mid point of the clavicle
• The anterior and posterior axillary lines- drop
vertically from the anterior and posterior axillary
folds (the muscle masses that border the axilla).
• The mid axillary lines- drop from the apexes of the
axilla.
• The scapular lines – drop from the inferior angles of
the scapulas
• The mid sternal and vertebral lines precise; others
are estimated.
• These lines drop vertically in the middle of the
sternum and the vertebral column respectively.
• The mid clavicular lines –drop vertically from the
mid point of the clavicle
• The anterior and posterior axillary lines- drop
vertically from the anterior and posterior axillary
folds (the muscle masses that border the axilla).
• The mid axillary lines- drop from the apexes of the
axilla.
• The scapular lines – drop from the inferior angles of
the scapulas
17
20. LUNGS, FISSURES AND LOBES
• Antreriorly, the apex of each lung rises about 2-4
cm above the inner third of the clavicle.
• The lower border of the lung crosses the 6th rib
at the mid clavicular line and the 8th rib at the
mid axillary line.
• Posteriorly, the lungs extend from just above the
scapula to about the level of the tenth thoracic
spinous process on quite respiration.
• Each lung is divided about in half by an oblique
(fissure).
• Antreriorly, the apex of each lung rises about 2-4
cm above the inner third of the clavicle.
• The lower border of the lung crosses the 6th rib
at the mid clavicular line and the 8th rib at the
mid axillary line.
• Posteriorly, the lungs extend from just above the
scapula to about the level of the tenth thoracic
spinous process on quite respiration.
• Each lung is divided about in half by an oblique
(fissure).
20
21. Cont…
• The right lung is further divided by the
horizontal (minor) fissure.
• Anteriorly, this fissure runs close to the fourth
rib and meets the oblique fissure in the mid
axillary line near the 5th rib.
• There fore, the right lung has three lobes and
the left lung has two lobes.
• The right lung is further divided by the
horizontal (minor) fissure.
• Anteriorly, this fissure runs close to the fourth
rib and meets the oblique fissure in the mid
axillary line near the 5th rib.
• There fore, the right lung has three lobes and
the left lung has two lobes.
21
25. LOCATIONS ON THE CHEST
Be familiar with general anatomic terms
used to locate chest findings, such as:
oSupraclavicular—above the clavicles
oInfraclavicular—below the clavicles
oInterscapular—between the scapulae
oInfrascapular—below the scapula
oBases of the lungs—the lowermost portions
oUpper, middle, and lower lung fields
Be familiar with general anatomic terms
used to locate chest findings, such as:
oSupraclavicular—above the clavicles
oInfraclavicular—below the clavicles
oInterscapular—between the scapulae
oInfrascapular—below the scapula
oBases of the lungs—the lowermost portions
oUpper, middle, and lower lung fields
25
26. THE TRACHEA AND MAJOR BRONCHI
Breath sounds over the trachea and bronchi
have a different quality than breath sounds over
the lung parenchyma.
Be sure you know the location of these
structures.
The trachea bifurcates into its mainstem bronchi
at the levels of the sternal angle anteriorly and
the T4 spinous process posteriorly.
Breath sounds over the trachea and bronchi
have a different quality than breath sounds over
the lung parenchyma.
Be sure you know the location of these
structures.
The trachea bifurcates into its mainstem bronchi
at the levels of the sternal angle anteriorly and
the T4 spinous process posteriorly.
26
28. EXAMINING THE THORAX AND THE LUNGS
General guidelines
Expose the chest fully
Proceed in an orderly fashion: inspection,
palpation, percussion, and finally auscultation
Compare one side with the other
Examine the posterior thorax and lungs while the pt
is still in a sitting position.
The pt’s arms should be folded across the chest
with hands resting, if possible on the opposite
shoulder as this position moves the scapula apart
and increases your access to the lung fields.
General guidelines
Expose the chest fully
Proceed in an orderly fashion: inspection,
palpation, percussion, and finally auscultation
Compare one side with the other
Examine the posterior thorax and lungs while the pt
is still in a sitting position.
The pt’s arms should be folded across the chest
with hands resting, if possible on the opposite
shoulder as this position moves the scapula apart
and increases your access to the lung fields. 28
29. Cont…
Ask the pt to lie supine while examining the
anterior chest.
This position makes examining women easier,
and wheezes, if present, are more likely to be
heard.
Other wise the sitting position is also
satisfactory.
Ask the pt to lie supine while examining the
anterior chest.
This position makes examining women easier,
and wheezes, if present, are more likely to be
heard.
Other wise the sitting position is also
satisfactory.
29
30. Cont…
When you must examine the chest by rolling to
one side and to the other, percuss the upper
lung and auscultate both lungs in each position.
Because ventilation is relatively greater in the
dependant lung, the chances of hearing
wheezes or crackles are greater on the
dependant side.
Relate all other findings in the thorax with
findings such as shape of the fingernails and
position of the trachea or cyanosis
When you must examine the chest by rolling to
one side and to the other, percuss the upper
lung and auscultate both lungs in each position.
Because ventilation is relatively greater in the
dependant lung, the chances of hearing
wheezes or crackles are greater on the
dependant side.
Relate all other findings in the thorax with
findings such as shape of the fingernails and
position of the trachea or cyanosis
30
31. CONCERNING SYMPTOMS OF
RESPIRATORY SYSTEM
o CHEST PAIN:
Complaints of chest pain or chest discomfort raise
the specter of heart disease, but often arise from
structures in the thorax and lung as well.
To assess this symptom, you must pursue a dual
investigation of both thoracic and cardiac
causes.
o CHEST PAIN:
Complaints of chest pain or chest discomfort raise
the specter of heart disease, but often arise from
structures in the thorax and lung as well.
To assess this symptom, you must pursue a dual
investigation of both thoracic and cardiac
causes.
31
32. o DYSPNEA
• is a nonpainful but uncomfortable awareness of
breathing that is inappropriate to the level of
exertion.
• This serious symptom warrants a full
explanation and assessment, since dyspnea
commonly results from cardiac or pulmonary
disease.
• Ask “Have you had any difficulty breathing?”
• is a nonpainful but uncomfortable awareness of
breathing that is inappropriate to the level of
exertion.
• This serious symptom warrants a full
explanation and assessment, since dyspnea
commonly results from cardiac or pulmonary
disease.
• Ask “Have you had any difficulty breathing?”
32
33. Cont…
• Find out when the symptom occurs, at rest or
with exercise, and how much effort produces
onset.
• Because of variations in age, body weight, and
physical fitness, there is no absolute scale for
quantifying dyspnea.
• Anxious patients may have episodic dyspnea
during both rest and exercise, and
hyperventilation, or rapid, shallow breathing.
• Find out when the symptom occurs, at rest or
with exercise, and how much effort produces
onset.
• Because of variations in age, body weight, and
physical fitness, there is no absolute scale for
quantifying dyspnea.
• Anxious patients may have episodic dyspnea
during both rest and exercise, and
hyperventilation, or rapid, shallow breathing.
33
34. o WHEEZES
• are musical respiratory sounds that may be
audible both to the pt and to others.
• Wheezing suggests partial airway obstruction
from secretions, tissue inflammation, or a
foreign body.
o COUGH
• is a common symptom that ranges in
significance from trivial to ominous.
• Typically, cough is a reflex response to stimuli
that irritate receptors in the larynx, trachea, or
large bronchi.
• are musical respiratory sounds that may be
audible both to the pt and to others.
• Wheezing suggests partial airway obstruction
from secretions, tissue inflammation, or a
foreign body.
o COUGH
• is a common symptom that ranges in
significance from trivial to ominous.
• Typically, cough is a reflex response to stimuli
that irritate receptors in the larynx, trachea, or
large bronchi. 34
35. • These stimuli include mucus, pus, and blood, as
well as external agents such as dusts, foreign
bodies, or even extremely hot or cold air.
• Other causes include inflammation of the
respiratory mucosa and pressure or tension in
the air passages from a tumor or enlarged
peribronchial lymph nodes.
• Although cough typically signals a problem in
the respiratory tract, it may also be
cardiovascular in origin.
• These stimuli include mucus, pus, and blood, as
well as external agents such as dusts, foreign
bodies, or even extremely hot or cold air.
• Other causes include inflammation of the
respiratory mucosa and pressure or tension in
the air passages from a tumor or enlarged
peribronchial lymph nodes.
• Although cough typically signals a problem in
the respiratory tract, it may also be
cardiovascular in origin.
35
36. Cont…
Ask whether the cough is dry or produces
sputum, or phlegm.
Ask the patient to describe the volume of any
sputum and its color, odor, and consistency.
Cough is an important symptom of left-sided
heart failure.
Dry hacking cough in Mycoplasmal pneumonia;
Productive cough in bronchitis, viral or bacterial
pneumonia
Ask whether the cough is dry or produces
sputum, or phlegm.
Ask the patient to describe the volume of any
sputum and its color, odor, and consistency.
Cough is an important symptom of left-sided
heart failure.
Dry hacking cough in Mycoplasmal pneumonia;
Productive cough in bronchitis, viral or bacterial
pneumonia
36
37. Cont…
Foul-smelling sputum in anaerobic lung
abscess;
tenacious sputum in cystic fibrosis
Large volumes of purulent sputum in
bronchiectasis or lung abscess
Foul-smelling sputum in anaerobic lung
abscess;
tenacious sputum in cystic fibrosis
Large volumes of purulent sputum in
bronchiectasis or lung abscess
37
38. o HEMOPTYSIS
• is the coughing up of blood from the lungs;
• For pts reporting hemoptysis, assess the
volume of blood produced as well as the other
sputum attributes;
• Ask about the related setting and activity and
any associated symptoms.
• Before using the term “hemoptysis,” try to
confirm the source of the bleeding by both
history and physical examination.
• is the coughing up of blood from the lungs;
• For pts reporting hemoptysis, assess the
volume of blood produced as well as the other
sputum attributes;
• Ask about the related setting and activity and
any associated symptoms.
• Before using the term “hemoptysis,” try to
confirm the source of the bleeding by both
history and physical examination.
38
39. Cont…
• Blood or blood-streaked material may originate
in the mouth, pharynx, or gastrointestinal tract
and is easily mislabeled.
• When vomited, it probably originates in the
gastrointestinal tract.
• Occasionally, however, blood from the
nasopharynx or the gastrointestinal tract is
aspirated and then coughed out.
• Blood originating in the stomach is usually
darker than blood from the respiratory tract and
may be mixed with food particles.
• Blood or blood-streaked material may originate
in the mouth, pharynx, or gastrointestinal tract
and is easily mislabeled.
• When vomited, it probably originates in the
gastrointestinal tract.
• Occasionally, however, blood from the
nasopharynx or the gastrointestinal tract is
aspirated and then coughed out.
• Blood originating in the stomach is usually
darker than blood from the respiratory tract and
may be mixed with food particles. 39
40. Inspection
1.Inspect the shape of the chest.
In the normal adult the thorax is wider than
it is deep (the anterior-posterior diameter is
about half of the lateral diameter ).
AP= ½ LD diameter
1.Inspect the shape of the chest.
In the normal adult the thorax is wider than
it is deep (the anterior-posterior diameter is
about half of the lateral diameter ).
AP= ½ LD diameter
40
41. Cont’d…
A barrel chest has an increased AP diameter.
This shape is normal during infancy, and often
accompanies normal aging and chronic
obstructive diseases.
A funnel chest is characterized by a
depression in the lower portion of the
sternum.
Compression of the heart and great vessels
may cause murmurs.
A barrel chest has an increased AP diameter.
This shape is normal during infancy, and often
accompanies normal aging and chronic
obstructive diseases.
A funnel chest is characterized by a
depression in the lower portion of the
sternum.
Compression of the heart and great vessels
may cause murmurs.
41
42. Cont’d…
A flail chest is unstable chest resulting when
multiple ribs are fractured.
Because descent of the diaphragm decreases
intra thoracic pressure on inspiration, the
injured area caves inward; on expiration, it
moves outward (paradoxical respiration).
A flail chest is unstable chest resulting when
multiple ribs are fractured.
Because descent of the diaphragm decreases
intra thoracic pressure on inspiration, the
injured area caves inward; on expiration, it
moves outward (paradoxical respiration).
42
43. Cont’d….
In a pigeon chest, the sternum is displaced
anteriorly, increasing the anterio-posterior
diameter.
The costal cartilages adjacent to the sternum are
depressed.
In thoracic kypho-scoliosis, abnormal spinal
curvatures and vertebral rotation deform the
chest.
Distortion of the underlying lungs may make
interpretation of lung findings very difficult.
In a pigeon chest, the sternum is displaced
anteriorly, increasing the anterio-posterior
diameter.
The costal cartilages adjacent to the sternum are
depressed.
In thoracic kypho-scoliosis, abnormal spinal
curvatures and vertebral rotation deform the
chest.
Distortion of the underlying lungs may make
interpretation of lung findings very difficult.
43
44. Cont’d…
Kyphosis-posterior curvature of the spine
Lordosis- Anterior curvature of the spine
Scoliosis-Lateral curvature of the spine
Inspect any other deformity or asymmetry
both at rest and while the patient is taking
deep breath.
Kyphosis-posterior curvature of the spine
Lordosis- Anterior curvature of the spine
Scoliosis-Lateral curvature of the spine
Inspect any other deformity or asymmetry
both at rest and while the patient is taking
deep breath.
44
48. 2.Inspect respiratory pattern
(rate, depth, rhythm, effort)
Normal respiration is 12-20 times per minute
each phase taking about 4-6 seconds, almost
regular, and quite and spontaneous.
On quite respiration, the chest expands 1-2
inches in adults.
Normal respiration is 12-20 times per minute
each phase taking about 4-6 seconds, almost
regular, and quite and spontaneous.
On quite respiration, the chest expands 1-2
inches in adults.
48
49. Cont’d…
Conditions such as restrictive lung diseases,
pleuritc chest pain, and elevated diaphragm
produce rapid and shallow breathing often
called tachypnea.
Rapid and deep breathing is called hyperpnea,
hyper ventilation.
It may be caused by exercise, anxiety, or
metabolic acidosis among other causes.
If the hyperventilated patient is comatose,
consider infarction, hypoxia, or hypoglycemia
affecting the Pons.
Conditions such as restrictive lung diseases,
pleuritc chest pain, and elevated diaphragm
produce rapid and shallow breathing often
called tachypnea.
Rapid and deep breathing is called hyperpnea,
hyper ventilation.
It may be caused by exercise, anxiety, or
metabolic acidosis among other causes.
If the hyperventilated patient is comatose,
consider infarction, hypoxia, or hypoglycemia
affecting the Pons.
49
50. Cheyne-stokes breathing, periods of deep rapid
breathing alternate with periods of no
breathing,
May be normal in children and aging people
during sleep.
Bradypnea (slow breathing) may be caused by
diabetic coma, drugs or increased intracranial
pressure.
Cheyne-stokes breathing, periods of deep rapid
breathing alternate with periods of no
breathing,
May be normal in children and aging people
during sleep.
Bradypnea (slow breathing) may be caused by
diabetic coma, drugs or increased intracranial
pressure.
50
51. 3. Observe for cyanosis
Blue discoloration of the skin, nail beds or
mucous membrane when there is at least
5 gm free Hgb in the blood.
Evaluate the patient for central cyanosis
and peripheral cyanosis.
Blue discoloration of the skin, nail beds or
mucous membrane when there is at least
5 gm free Hgb in the blood.
Evaluate the patient for central cyanosis
and peripheral cyanosis.
51
52. 4. Movement of the Chest
One has to inspect whether both sides of the
chest is moving symmetrically or not.
Causes of asymmetrical chest expansion are:-
Pleural effusion.
Pneumothorax.
Extensive consolidate ion.
Atelectasis.
Pulmonary Fibrosis.
One has to inspect whether both sides of the
chest is moving symmetrically or not.
Causes of asymmetrical chest expansion are:-
Pleural effusion.
Pneumothorax.
Extensive consolidate ion.
Atelectasis.
Pulmonary Fibrosis.
52
53. Palpation
Palpation has the following uses:
1.Identification of tender areas: palpate any area
where pain has been reported or lesions are
evident.
E.g. Intercostal tenderness over inflamed pleura
2.Assessment of observed abnormalities example
masses
E.g. Bruises over a fractured rib Although rare,
sinus tracts usually indicate infection of the
underlying pleura and lung (as in tuberculosis).
Palpation has the following uses:
1.Identification of tender areas: palpate any area
where pain has been reported or lesions are
evident.
E.g. Intercostal tenderness over inflamed pleura
2.Assessment of observed abnormalities example
masses
E.g. Bruises over a fractured rib Although rare,
sinus tracts usually indicate infection of the
underlying pleura and lung (as in tuberculosis).
53
54. Cont’d…
3.Assessment of respiratory expansion to
determine range and symmetry of respiratory
movements.
Place your thumbs about at the level of and
parallel to the tenth ribs posteriorly and at the
level of the lower costal margin in the mid
line anteriorly, your hands grasping the lateral
rib cage.
3.Assessment of respiratory expansion to
determine range and symmetry of respiratory
movements.
Place your thumbs about at the level of and
parallel to the tenth ribs posteriorly and at the
level of the lower costal margin in the mid
line anteriorly, your hands grasping the lateral
rib cage.
54
55. Cont’d…
As you position your hands, slide them
medially in order to raise loose skin folds
between your thumbs.
Ask the patient to breath deeply and watch
the divergence of your thumbs or the return of
the folds of skin during inspiration.
Normally divergence should be symmetrical
and range of expansion should be not less than
1-2 inches.
As you position your hands, slide them
medially in order to raise loose skin folds
between your thumbs.
Ask the patient to breath deeply and watch
the divergence of your thumbs or the return of
the folds of skin during inspiration.
Normally divergence should be symmetrical
and range of expansion should be not less than
1-2 inches.
55
58. Causes of unilateral decrease or delay in
chest expansion include:-
Chronic fibrotic disease of the underlying lung
or pleura,
Pleural effusion,
Lobar pneumonia.
Pleural pain with associated splinting, and
unilateral bronchial obstruction.
Causes of unilateral decrease or delay in
chest expansion include:-
Chronic fibrotic disease of the underlying lung
or pleura,
Pleural effusion,
Lobar pneumonia.
Pleural pain with associated splinting, and
unilateral bronchial obstruction.
58
59. 4.Assessment of tactile fremitus (the palpable
vibrations transmitted through the broncho-
pulmonary tree to the chest wall when the patient
speaks):
Ask the patient to repeat words ‘99’ or ‘one-one-
one’ and with the ball of your hand (the bony part
of the palm at the base of the fingers) or the ulnar
surface of your hand, palpate and compare
symmetrical areas of the lung.
4.Assessment of tactile fremitus (the palpable
vibrations transmitted through the broncho-
pulmonary tree to the chest wall when the patient
speaks):
Ask the patient to repeat words ‘99’ or ‘one-one-
one’ and with the ball of your hand (the bony part
of the palm at the base of the fingers) or the ulnar
surface of your hand, palpate and compare
symmetrical areas of the lung. 59
60. Cont’d…
Identify any areas of increased, decreased or
absent fremitus and locate them.
Fremitus is typically more prominent in the
interscapular area than in the lower lung fields,
And is often more prominent on the right side than
on the left.
It disappears below the diaphragm.
Identify any areas of increased, decreased or
absent fremitus and locate them.
Fremitus is typically more prominent in the
interscapular area than in the lower lung fields,
And is often more prominent on the right side than
on the left.
It disappears below the diaphragm.
60
61. Cont’d…
Fremitus is decreased or absent when the
voice is soft, the transmissions of the vibrations
from the larynx to the surface of the chest wall
is impended as in:
Obstructed bronchus,
Chronic obstructive diseases,
Separation of the pleural surfaces by fluid,
air, fibrosis (pleural thickening), infiltrating
tumor or when there is very thick chest wall.
Fremitus is decreased or absent when the
voice is soft, the transmissions of the vibrations
from the larynx to the surface of the chest wall
is impended as in:
Obstructed bronchus,
Chronic obstructive diseases,
Separation of the pleural surfaces by fluid,
air, fibrosis (pleural thickening), infiltrating
tumor or when there is very thick chest wall.
61
62. Cont’d…
On the contrary, fremitus is increased when
transmission is increased as through the
consolidated lung of lobar pneumonia.
Anteriorly fremitus is decreased or absent over
pericardium.
When examining women gently displace the
breast as necessary.
On the contrary, fremitus is increased when
transmission is increased as through the
consolidated lung of lobar pneumonia.
Anteriorly fremitus is decreased or absent over
pericardium.
When examining women gently displace the
breast as necessary.
62
65. Percussion
Percussion of the thorax has three main
purposes:
To determine whether the underlying tissues
are air filled, fluid filled or solid with in 5-7 cm
in to the chest wall.
To estimate diaphragmatic excursion
To identify level of diaphragmatic dullness
Percussion of the thorax has three main
purposes:
To determine whether the underlying tissues
are air filled, fluid filled or solid with in 5-7 cm
in to the chest wall.
To estimate diaphragmatic excursion
To identify level of diaphragmatic dullness
65
66. Techniques:
Hyper extend the middle finger of your left
hand (pleximeter finger) and press its distal
iterphalangeal joint on the surface to be
percussed (avoid surface contact by any other
part of the hand as it dumps the vibrations).
Techniques:
Hyper extend the middle finger of your left
hand (pleximeter finger) and press its distal
iterphalangeal joint on the surface to be
percussed (avoid surface contact by any other
part of the hand as it dumps the vibrations).
66
67. Cont’d…
Position your right forearm quite close to the
surface with the hand cocked up ward and, with
a quick, sharp, but relaxed wrist motion strike
the pleximetre finger with the tip of the partially
right middle finger.
Position your right forearm quite close to the
surface with the hand cocked up ward and, with
a quick, sharp, but relaxed wrist motion strike
the pleximetre finger with the tip of the partially
right middle finger.
67
68. Cont’d…
You should always use the lightest percussion
that produces a clear note; a thick chest wall
requires heavier percussion than a thin one.
Remember to keep your technique constant
in comparing two areas.
You should always use the lightest percussion
that produces a clear note; a thick chest wall
requires heavier percussion than a thin one.
Remember to keep your technique constant
in comparing two areas.
68
71. Cont’d…
Interpretation of percussion findings is based on
the following five percussion notes:
Flat- this is a type of note we get by
percussing over the thigh; pathological
examples include massive pleural effusion,
tumor, etc.
Dull: a type of note similar to the one
detected over normal liver. Pathological
examples include lobar pneumonia, pleural
effusion, hemothorax, etc.
Interpretation of percussion findings is based on
the following five percussion notes:
Flat- this is a type of note we get by
percussing over the thigh; pathological
examples include massive pleural effusion,
tumor, etc.
Dull: a type of note similar to the one
detected over normal liver. Pathological
examples include lobar pneumonia, pleural
effusion, hemothorax, etc.
71
72. Cont’d…
Resonance: this is the percussion note of
normal lung tissue though it can’t rule out
lung abnormalities.
Pathological example, chronic bronchitis.
Hyper resonance: this note is detected
when there is larger amount of air
contained under the surface to be
percussed
Resonance: this is the percussion note of
normal lung tissue though it can’t rule out
lung abnormalities.
Pathological example, chronic bronchitis.
Hyper resonance: this note is detected
when there is larger amount of air
contained under the surface to be
percussed
72
73. Cont’d…
Hyper resonance is heard in emphysema
and bronchial asthma (in which case it is
generalized) or pneumothorax (in which
case it is localized).
Tympani: this note can be learned by
percussing over a puffed out cheek or over
most areas of the stomach.
Pathological example, large pneumothorax.
Hyper resonance is heard in emphysema
and bronchial asthma (in which case it is
generalized) or pneumothorax (in which
case it is localized).
Tympani: this note can be learned by
percussing over a puffed out cheek or over
most areas of the stomach.
Pathological example, large pneumothorax.
73
75. Identifying The Level Of
Diaphragmatic Dullness
Starting above the expected level of dullness,
percuss down ward until dullness replaces
resonance during quiet respiration.
Check the level of this change near the middle
of the hemi thorax and also more laterally.
An abnormally high level may suggest pleural
effusion, or high diaphragm as from
atelectasis or diaphragmatic paralysis.
Starting above the expected level of dullness,
percuss down ward until dullness replaces
resonance during quiet respiration.
Check the level of this change near the middle
of the hemi thorax and also more laterally.
An abnormally high level may suggest pleural
effusion, or high diaphragm as from
atelectasis or diaphragmatic paralysis.
75
77. Estimating Diaphragmatic Excursion
Ask the patient to exhale fully and keep.
Percuss the posterior chest down from area of
resonance to area of dullness and mark.
Then ask the patient to breath in deep and
hold, continue percussing down until
resonance changes to dullness and mark.
Ask the patient to exhale fully and keep.
Percuss the posterior chest down from area of
resonance to area of dullness and mark.
Then ask the patient to breath in deep and
hold, continue percussing down until
resonance changes to dullness and mark.
77
78. Cont’d…
Measure the vertical distance between the
two points.
Do the same for the other side.
Normally it should be 5-6 cm, with the
possibility of the right side to be 2cm higher
than the left side.
Measure the vertical distance between the
two points.
Do the same for the other side.
Normally it should be 5-6 cm, with the
possibility of the right side to be 2cm higher
than the left side.
78
79. Auscultation
It is the most important examining technique
for assessing airflow through the broncho-
tracheal tree.
Instruct the patient to breath deeply through
an open mouth.
It is the most important examining technique
for assessing airflow through the broncho-
tracheal tree.
Instruct the patient to breath deeply through
an open mouth.
79
80. Cont’d…
Using the diaphragm of the stethoscope,
auscultate areas suggested by percussion and
compare symmetrical areas.
You should auscultate between the ribs not at
the ribs.
In children, the interspaces are small and
there fore you better use the bell of your
stethoscope pressed tightly.
Using the diaphragm of the stethoscope,
auscultate areas suggested by percussion and
compare symmetrical areas.
You should auscultate between the ribs not at
the ribs.
In children, the interspaces are small and
there fore you better use the bell of your
stethoscope pressed tightly.
80
81. Cont’d…
If you hear or suspect abnormality, auscultate
adjacent areas to describe the extent of the
abnormality.
Be alert for patient discomfort due to
hyperventilation (example light headedness,
faintness), and allow the patient to rest as
needed.
If you hear or suspect abnormality, auscultate
adjacent areas to describe the extent of the
abnormality.
Be alert for patient discomfort due to
hyperventilation (example light headedness,
faintness), and allow the patient to rest as
needed.
81
82. Cont’d…
Auscultation has the following three main
purposes:
To identify whether the breath sounds are
decreased, absent or abnormally located
To identify the presence of added (adventitious)
sounds
To identify extent of transmission of voice sounds
Auscultation has the following three main
purposes:
To identify whether the breath sounds are
decreased, absent or abnormally located
To identify the presence of added (adventitious)
sounds
To identify extent of transmission of voice sounds
82
83. The Normal Breath Sounds
1.Vesicular breath sound that is characterized by:
Inspiratory sounds lasting longer than
expiratory ones.
Soft and low pitched.
No pause between expiration and
inspiration.
Heard through inspiration and one–third of
expiration.
Normally heard over most of both lungs.
1.Vesicular breath sound that is characterized by:
Inspiratory sounds lasting longer than
expiratory ones.
Soft and low pitched.
No pause between expiration and
inspiration.
Heard through inspiration and one–third of
expiration.
Normally heard over most of both lungs.
83
84. 2.Bronchial Breath
Sound that is characterized by:
Loud and relatively high pitched
Expiratory sounds lasting longer than
inspiratory ones
Short silent period between inspiration and
expiration
The normal location is over the manubrium
if heard at all
Sound that is characterized by:
Loud and relatively high pitched
Expiratory sounds lasting longer than
inspiratory ones
Short silent period between inspiration and
expiration
The normal location is over the manubrium
if heard at all
84
85. 3.Broncho-Vesicular Breath
sounds are characterized by:
Intermediate in intensity and pitch
Inspiratory and expiratory sounds are about
equal in duration
A silent gap between inspiration and
expiration may or may not be present
Normally it can be heard in the first and
second interspaces anteriorly and between
the scapulas posteriorly.
sounds are characterized by:
Intermediate in intensity and pitch
Inspiratory and expiratory sounds are about
equal in duration
A silent gap between inspiration and
expiration may or may not be present
Normally it can be heard in the first and
second interspaces anteriorly and between
the scapulas posteriorly.
85
86. Cont’d…
If bronchial or broncho-vesicular sounds are
heard in locations distant from those listed,
suspect that air filled lung has been replaced
by fluid filled or solid lung tissue.
Breathed sounds may be decreased when
airflow is decreased (example obstructive lung
disease or muscular weakness) or when the
transmission of sound is poor (example in
pleural effusion, pneumothorax, or
emphysema).
If bronchial or broncho-vesicular sounds are
heard in locations distant from those listed,
suspect that air filled lung has been replaced
by fluid filled or solid lung tissue.
Breathed sounds may be decreased when
airflow is decreased (example obstructive lung
disease or muscular weakness) or when the
transmission of sound is poor (example in
pleural effusion, pneumothorax, or
emphysema).
86
88. Added Sounds
These are sounds that are superimposed on
the usual breath sounds.
The common ones are described here.
Crackles/rales/crepitation:
discontinuous/intermittent, nonmusical
sounds of brief-like dots in time that may be
fine (soft and brief) or coarse (louder and
not quit so brief).
These are sounds that are superimposed on
the usual breath sounds.
The common ones are described here.
Crackles/rales/crepitation:
discontinuous/intermittent, nonmusical
sounds of brief-like dots in time that may be
fine (soft and brief) or coarse (louder and
not quit so brief).
88
89. Cont’d…
Crackles are caused by air babbles flowing
through secretions or lightly closed airways
during respiration.
They also result from a series of tiny
explosions when small airways, deflated
during expiration, pop open during inspiration
Example interstitial lung disease, early
congestive heart failure, pneumonia.
Crackles are caused by air babbles flowing
through secretions or lightly closed airways
during respiration.
They also result from a series of tiny
explosions when small airways, deflated
during expiration, pop open during inspiration
Example interstitial lung disease, early
congestive heart failure, pneumonia.
89
90. Cont’d…
If you hear crackles, note whether fine(soft,
high pitched and very brief) or coarse(some
what louder, lower in pitch and not quite so
brief), their timing in the respiratory cycle,
location on the chest wall, persistence of their
pattern from breath to breath and any change
after coughing or changing position.
Note also that in some normal people, crackles
may be heard at the lung bases anteriorly after
maximal expiration, and that crackles in
dependant portions of the lungs may also occur
after prolonged recumbency.
If you hear crackles, note whether fine(soft,
high pitched and very brief) or coarse(some
what louder, lower in pitch and not quite so
brief), their timing in the respiratory cycle,
location on the chest wall, persistence of their
pattern from breath to breath and any change
after coughing or changing position.
Note also that in some normal people, crackles
may be heard at the lung bases anteriorly after
maximal expiration, and that crackles in
dependant portions of the lungs may also occur
after prolonged recumbency.
90
91. Cont’d…
Wheezes: relatively high-pitched, continuous,
musical sounds which are longer than crackles
and like dashes in time.
Wheezes are often audible through mouth or
chest wall.
Wheezes: relatively high-pitched, continuous,
musical sounds which are longer than crackles
and like dashes in time.
Wheezes are often audible through mouth or
chest wall.
91
92. Cont’d…
It occurs when air flows through bronchi that
are narrowed to the point of closure.
Generalized wheezes are commonly caused by
asthma, chronic bronchitis and congestive
heart failure (cardiac asthma).
A persistent localized wheeze suggests a
partial obstruction of a bronchus, as by a
tumor or foreign body.
It may be inspiratory, expiratory or both.
It occurs when air flows through bronchi that
are narrowed to the point of closure.
Generalized wheezes are commonly caused by
asthma, chronic bronchitis and congestive
heart failure (cardiac asthma).
A persistent localized wheeze suggests a
partial obstruction of a bronchus, as by a
tumor or foreign body.
It may be inspiratory, expiratory or both.
92
93. Cont’d…
Stridor is a wheeze that is entirely or
predominantly inspiratory.
It indicates a partial obstruction of the larynx
or trachea and is a medical emergency.
Rhonchi - are continuous sounds with snoring
quality; it suggests secretions in the larger
airways.
Wheezes need adequate characterization as
that of crackles.
Stridor is a wheeze that is entirely or
predominantly inspiratory.
It indicates a partial obstruction of the larynx
or trachea and is a medical emergency.
Rhonchi - are continuous sounds with snoring
quality; it suggests secretions in the larger
airways.
Wheezes need adequate characterization as
that of crackles.
93
94. Cont’d…
Pleural friction rub: Are discrete granting
sounds that appear continuous because they
are numerous.
Pleural friction rub are usually confined to a
small area of chest wall and typically heard in
both phases of the respiration.
Pleural friction rub: Are discrete granting
sounds that appear continuous because they
are numerous.
Pleural friction rub are usually confined to a
small area of chest wall and typically heard in
both phases of the respiration.
94
95. Cont…
Wheezes: relatively high-pitched, continuous,
musical sounds which are longer than crackles
and like dashes in time. Wheezes are often
audible through mouth or chest wall.
Wheezes: relatively high-pitched, continuous,
musical sounds which are longer than crackles
and like dashes in time. Wheezes are often
audible through mouth or chest wall.
95
96. Cont…
It occurs when air flows through bronchi that
are narrowed to the point of closure.
Generalized wheezes are commonly caused by
asthma, chronic bronchitis and congestive
heart failure (cardiac asthma).
A persistent localized wheeze suggests a
partial obstruction of a bronchus, as by a
tumor or foreign body.
It may be inspiratory, expiratory or both.
It occurs when air flows through bronchi that
are narrowed to the point of closure.
Generalized wheezes are commonly caused by
asthma, chronic bronchitis and congestive
heart failure (cardiac asthma).
A persistent localized wheeze suggests a
partial obstruction of a bronchus, as by a
tumor or foreign body.
It may be inspiratory, expiratory or both.
96
97. Transmitted voice sounds
If you hear abnormally located broncho-
vesicular breath sounds or bronchial breath
sounds, continue on to assess transmitted voice
sounds.
This can be done in the following ways.
Ask the patient to say ‘99’,’ arba-arat’ or
‘afurtemi-afur’ as applicable and auscultate
over the auscultatory areas with your
stethoscope.
If you hear abnormally located broncho-
vesicular breath sounds or bronchial breath
sounds, continue on to assess transmitted voice
sounds.
This can be done in the following ways.
Ask the patient to say ‘99’,’ arba-arat’ or
‘afurtemi-afur’ as applicable and auscultate
over the auscultatory areas with your
stethoscope.
97
98. Cont…
Normally the sounds transmitted through the
chest wall are muffled and indistinct.
Louder clearer voice sounds heard through
the stethoscope (bronchophony) suggest that
air-filled lung has become airless.
Normally the sounds transmitted through the
chest wall are muffled and indistinct.
Louder clearer voice sounds heard through
the stethoscope (bronchophony) suggest that
air-filled lung has become airless.
98
99. Cont…
Ask the patient to say ‘ee’.
Normally, you hear a muffled long “e”. When
‘ee’ is heard as ‘ay’, an e-to-a change,
(egohpony), and the quality sounds nasal, it
suggests that the lung has been changed to
airless.
Ask the patient to say ‘ee’.
Normally, you hear a muffled long “e”. When
‘ee’ is heard as ‘ay’, an e-to-a change,
(egohpony), and the quality sounds nasal, it
suggests that the lung has been changed to
airless.
99
100. Cont…
Ask the patient to whisper ‘99’ or one-two-
three’ and auscultate.
The whispered voice is normally heard faintly
and indistinctly. Louder clearer whispered
sounds (whispered pectoriloquy) suggest
airless lung.
Ask the patient to whisper ‘99’ or one-two-
three’ and auscultate.
The whispered voice is normally heard faintly
and indistinctly. Louder clearer whispered
sounds (whispered pectoriloquy) suggest
airless lung.
100
101. OUR DESTINY IS NOT
WRITTEN FOR US, BUT
BY US.
OUR DESTINY IS NOT
WRITTEN FOR US, BUT
BY US.
101
