introduction of respiratory system and clinical examination

2. • INTRDOUCTION
• Respiration is the process by which oxygen is given in CO2 is
given out.
• Normal respiratory rate at different ages:
AGE RESPIRATORY RATE
[breaths/min]
Premature baby 40-70
0-3 months 35-55
3-6 months 30-45
6-12 months 25-40
1-3 years 20-30
3-6 years 20-25
6-12 years 14-22Greater than 12 years 12-18

3. • Types of respiration: 2 types-
• External respiration: Exchange of gases b/w lungs and blood.
• Internal respiration: Exchange of gases b/w blood and tissue.
• Functional anatomy of respiratory tract:
• Respiratory tract is the anatomical structure through which air
moves in and out.
• The respiratory system consist of –
 Upper respiratory tract- upto larynx
 Lower respiratory tract - trachea to alveoli

4. Clinical anatomy of lungs-

9. LUNGS-
• The lungs are pair of respiratory organ situated at the thoracic
cavity.
• Right lung is bigger in size and has 3 lobes while left lung is
smaller and has 2 lobes.
• Pleura-
• Each lung is enclosed by a bilayered serous membrane called
pleura or pleural sac.

10. Respiratory tract and lobes of lung

11.  Pleura has two layers-outer parietal pleura and inner visceral pleura. .
 Pleural cavity-narrow space b/w two layers of pleura.
 {in some pathological conditions this cavity expands with
accumulation of air i.e.pneumothorax,water i.e.
hydrothorax,blood i.e. haemothorax,or pus i.e.pyothorax.
 Tracheobronchial tree-
 Trachea and bronchi together called tracheobronchialtree.
 Components of tracheobronchial tree-
 Trachea
 Primary bronchi which divides into left and right bronchi.
 Secondary bronchi
 Tertiary bronchi
 Bronchioles
 Terminal bronchiole
 Respiratory bronchiole.

13. CARINA
 Carina is the area where
trachea divides into two
primary bronchi.
 Right bronchus makes an angle
of 25 degree while left one
makes an angle of 45 degree.
 Foreign bodies mostly descend
into right bronchus.
 Carina of the trachea is a
sensitive area .when patient is
made to lie on her/his left side
secretions from right bronchial
tree flow towards the carina
due to effect of gravity.this
stimulate the cough reflex and
sputum is brought out.this is
called postural drainage.

14. Respiratory unit:
 Parenchyma of lung is formed by
the respiratory unit that forms the
terminal portion of respiratory
tract.
 Respiratory unit is defined as
structural and functional unit of
lung.
 Exchange of gases occurs only in
this part of respiratory tract.
 Structures of respiratory unit:
 Respiratory bronchioles
 Alveolar ducts
 Alveolar sacs
 Antrum
 alveoli

15. Inspiratory muscles Expiratory muscles
Primary- diaphragm and external
intercostal muscles.
Internal intercostal.
Accessory-
sternocleidomastoid,scalena,anterior
serrati,elevators of scapulae,pectorals.
Abdominal muscles.
• Mechanics of breathing:
• Respiratory muscles:
•

16. Movement of thoracic cage-
• Inspiration causes enlargement of thoracic cage b/c of
increase in all diameter.
• Change in size occurs due to movement of four units of
structures:
1. Thoracic lid{formed by manubrium sterni and first pair of ribs}-increase
AP diameter
2. Upper costal series{2nd-6th pair of ribs}-increase AP and transverse
diameter
• 2 types of movement.
 Pump handle –elevation of ribs and upward and forward movement of
sternum.-increase AP diameter.
 Bucket handle-central portion of ribs moves upward and outward-
increase transvrese diameter.
3. Lower costal series{7th-10th pair of ribs}
4. diaphragm

17. Diaphragm-
• Movement of diaphragm
increase the vertical diameter of
thoracic cage.
• Normally before inspiration
diaphragm is dome shape with
convexity facing upwards.
• During inspiration ,due to the
contraction ,muscle fibres are
shortened,but the central
tendinous portion is drawn
downwards,so the diaphragm is
flatened.
• Flattening of diaphragm
increases the vertical diameter
of thoracic cage.

18. Movement of lungs:
• During inspiration due to enlargement of thoracic cage,negative pressure
is increased in the thoracic cavity.it causes expansion of lungs.
• During expiration thoracic cavity decrease in size to the preinspiratory
position.
• Surfactant:
• Surfactant is a surface acting agent that is responsible for the lowering the
surface tension of a fluid.
• Surfactant that lines the epithelium of alveoli in lungs is known as
pulmonary surfactant.

19. Surfactant:
• Pulmonary surfactant is secreted by two types of cells:
• Type 2 alveolar epithelial cells.
• Clara cells.
• Functions:
• Reduce the surface tension in the alveoli of lungs and prevents collapsing
tendency of lungs.
• It plays an important role in the inflation of lungs after birth.
• In foetus,the secretion of surfactant begins after the 3rd month,the
presence of surfactant in the alveoli prevents the lungs from collapsing.

20. Functions:
• Another important function of surfactant is its role in
defense,within the lungs against infection and
inflammation.hydrophilic protein SP-A and SP-D destroy the
bacteria and virus by means of opsonization.
• Effect of deficiency of surfactant:
• Absence of surfactant in infants causes collapse of lungs and the condition
is called “RESPIRATORY DISTRESS SYNDROME” or “HYALINE MEMBRANE
DISEASE”
 Respiratory pressures:
• Intrapleural pressure:
• cause for negativity of intrapleural pressure :
• Pleural cavity is always lined by a thin layer of fluid that is secreted by visceral
layer of pleura.

21. • This fluid is constantly pumped from the pleural cavity into
the lymphatic vessels.Pumping of fluid creats the negative
pressure in the pleural cavity.
• `
• Intrapleural pressure becomes positive in “valsalva
maneuver”and in some pathological conditions such as
pneumothorax,pyothorax,haemothorax and hydrothorax
• Intra alveolar pressure or intrapulmonary.
• COMPLIANCE
• Compliance is the ability of lungs and thorax to expand.it is
defined as the change in volume per unit change in the
pressure.

22. • Significance of determining compliance -
• Determination of compliance is useful as it is the measure of
stiffness of lungs .Stiffer the lungs less the compliance.

23. History-
• Ask history of present illness with special emphasis on onset
[sudden,acute,subacute or insiduous].
• Major symptoms of respiratory system include-
o Cough
o Sputum production
o Breathlessness
o Chest pain
o Hemoptysis
o Wheeze/stridor
 cough- classification according to duration-
1. Acute cough[ 3 weeks]-
• Upper respiratory tract infection
• Pneumonia
• Pulmonary embolism

24. 2.Subacute cough- [3-8 weeks]
• Viral infection
• Post infective
• Post nasal drip
3.Chronic cough-
• Bronchial asthma
• Pulmonary TB
• Congestive cardiac failure
 Cough according to nature and their causes-

25. Nature of cough Possible causes
•Dry hacking cough
•Wet /productive/chesty spasmodic
cough.
•Paroxysmal cough with a whoop
and choking.
•Brassy or barking cough.
•Cough induced by feeding .
•Habit/psychogenic/throat clearing
cough.
Pharyngitis,tonsillitis,irritation of
throat.
Bronchitis,bronchial
asthma,congestive cardiac
failure,post nasal drip.
Pertussis, chlamydial pneumonai,
adenovirus infection.
Tracheitis,mediastinal lymph nodes.
Neuromotor disorders
,bronchospasm, GERD.
Short low amplitude brief bouts of
honking cough, disappear during play
or sleep.

26. • Sputum production-
o Consistency
o Amount
o Color
o Postural variation
o Smell
• Consistency-
• Serous- URTI, bronchoalveolar carcinoma
• Mucoid - bronchial asthma
• Mucopurulent - bacterial infection
• Amount-copious amount in bronchiectasis,lung abscess etc.

27. • Color-
• Yellow green - Bacterial infection.
• Pink frothy sputum- Pulmonary edema.
• Rusty sputum- Pneumococcal pneumonia
• Red current jelly sputum- klebsiella
• Blood tinged/streaking of sputum- Pulmonary tuberculosis.
• Postural variation- lung abscess,bronchiectasis
• Smell-
 Foul smell in lung abscess,bronchiectasis,anaerobic bacterial
infection

28. • Breathlessness/dyspnoea- breathlessness is an unpleasant
sensation of uncomfortable , rapid or difficult breathing.
• Tachypnoea and dyspnoea are suggestive of acute lower
respiratory tract infection, bronchospasm, atelactasis, and
compression of lungs.
• Grading of dyspnoea-[According to NYHA]-
I. Grade 1- No symptoms and no limitations on ordinary physical activity.
II. Grade 2- Mild symptoms and slight limitations during ordinary activity,
comfortable at rest.
III. Grade 3-Marked limitations in activity due to symptoms even during less
than ordinary activity. Comfortable only at rest.
IV. Grade 4-Severe limitations, experiences symptoms even while at rest.

29. • History of recurrent episodes of cough with breathing difficulties
are suggestive of bronchial asthma, bronchiectasis, foreign body ,
left to right shunt, and GERD.
• Chest pain-
• History of Pain in children is uncommon and may occurs due to
pleurisy,pericarditis,costochondritis and coronary insufficiency [
severe aortic stenosis or regurgitation , kawasaki disease.]
• Hemoptysis - Hemoptysis is uncommon in children and may occur
due to bronchiectasis, lung abscess, pulmonary edema, mitral
stenosis, tubercular cavity and bleeding disorders.
• Unlike hemetemisis haemoptysis is preceded by a bouts of cough
,the blood is bright red in color and small in quantity.

30. • Wheeze/ stridor – stridor is a harsh , vibratory ,high pitched
shrill or crowing noise caused by obstructed airflow.
• Common causes of stridor-
 Infections-
• viral –viral laryngitis, acute spasmodic laryngitis.
• Bacterial-diphtheric laryngitis,acute epiglottitis, retropharyngeal abscess[
quinsy]
• Fungal-candidal laryngitis
• Congenital malformation-
• Subglottic stenosis
• Laryngospasm in tetany and GERD
• Laryngeal edema-allergic[ angioedema] ,trauma due to
intubation and foreign body
• Laryngeal paralysis –birth trauma,arnold chiari malformation

31. General physical exmination-
• General condition
• Vitals-
 Temperature
 Pulse
 Respiratory rate and rhythm
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Lymphadenopathy

32. • Respiratory rate and rhythm-
• Normal rhythm of breathing is characterized by inspiration-
expiration- pause.
• Reversed rhythm i.e. expiratory grunt- inspiration- pause is
seen in children with acute lower respiratory infection.
• kussamual’s breathing-occurs in response to metabolic acidosis
due to severe diarrhea and dehydration, diabetic
ketoacidosis,inborn error of metabolism.

34. a
• Chyne-strokes
breathing-
• It occurs due to
depression of
respiratory centre
because of hypoxia
,meningitis, increased
intracranial pressure
and congestive heart
failure.

35. • Biot’s respiration-
• Occurs in children with
raised intracranial
pressure.

36. • WHO cut offs for fast breathing in under-5
children-
age Breaths/min
Birth-2months 60 or more
2-12 months 50 or more
1-5 years 40 or more

37. • Hands- The hands
should be looked for
clubbing, pallor or
cyanosis.
• Cyanosis-
The presence of severe
respiratory difficulty with
marked cyanosis is more
common due to pulmonary
disorder rather than
cardiac.

38. • ENT checkup- it is essential to rule out upper
respiratory tract infection ,otitis media and
sinusitis.
• Oral cavity- examine oral cavity and throat for any acute or
chronic infection.
• Nose- for any discharge or polyp.
• Allergic rhinitis- Itching of nose and eyes, rubbing of nose
with open palm ,horizontal crease over nasal bridge, dark
circles and allergic ‘shiners’ over lower eyelid.

39. • Clubbing-
• Pulmonary causes of
clubbing-
• Pulmonary suppuration
[bronchiectasis, lung
abscess, empyema]
• Other causes-
malabsorption syndrome,
ulcerative colitis ,cirrhosis
of liver etc.

40. Hypertrophic osteoarthropathy-
• Clubbing in association with pain over the wrist and ankles
because of subperiosteal bone formation over distal diaphysis
of radius, ulna ,tibia ,fibula.
• It may occur due to bronchiectasis.
• Venous pulses-
The presence of severly engorged non pulsatile jugular
veins are suggestive of mediastinal mass and may be
associated with facial plethora’ brassy cough’, hoarseness
,stridor or dysphagia.

41. • The sphenoid sinuses are present at birth and ethmoid and
maxillary sinuses are of clinical importance during early
childhood.The frontal sinuses are usually not present during
first 10 years of age.
• Chronic sinusitis is associated with nasal obstruction with
persistent mucopurulent discharge , slight puffinss of eyelids
and dark circles under the eyes.
• The important cause of chronic sinusitis include cleft palate,
nasal allergy ,kartagener’s syndrome or immotile cilia
syndrome.

42. Assessment of respiratory distress-
• The assessment of respiratory distress is assessd by
following criteria –
• Maternal status
• Severity of tacypnea, dyspnea and use of accessory
muscles of breathing
• Color- blue or pale
• Pulsus paradoxus and its severity
• Arterial oxygen saturation < 85% on pulse oximeter.
• Peak expiratory flow rate of less than 80% of the
predicted or actual average of the patient.

43. Peak expiratory flow rate
• Depending upon the
actual PEFR of the child
three categories are
identified-
• Green zone-PEFR within
80%
• Yellow zone- PEFR
between 50%-80%.
• Red zone –PEFR less than
50 %of predicted or
actual.

44. CLINICAL EXAMINATION-
• Best positions for examination at different ages-
0-3 months Examination table
3 months- 1 year Mother’s lap
1 – 3 years Standing or mother’s lap
After 3 years Examination table
Adolescent girl Female attendant ,mother or
nurse should be present at the
time of examination.

45. • Examination of respiratory system is carried out by-
• Inspection
• Palpation
• Percussion
• Auscultation
• Inspection-
• The exposed chest should be inspected by standing at the head or
foot side of the patient with eyes at the level of chest.
• The child,however,is best examined while sitting comfortably on a
stool or standing with arms hanging limply by the side
• Shape of the chest-
• It is nearly circular or cylindrical in infants and in adults bilaterally
symmetrical and elliptical in cross section with the narrower
diameter being anteroposterior .

46. Abnormal shapes of the chest-
• Pectus carinatum[Pigeon Chest]-
• There is an depression on either side of sternum often associated with
bead like enlargement at the costochondral junction [Ricket rosary].It is
found in rickets.
• Funnel chest[Pectus excavatum]-
• There is depression in the lower part of the sternum which may be
congenital following ricket in childhood.Found in Absent pectoralis
muscle,Marfan syndrome etc.
• Symmetry
• Note whether chest is bilaterally symmetrical or not.
• Note the distance of medial borders of scapula from midline on both the
sides which is useful to asses the any asymmetry of the chest.
• Drooping of one shoulder may occur in patients with fibrocaseous
tuberculosis.
• There is buldging of intercostal spaces in cases of pleural effusion and
empyema.

48. MOVEMENT OF THE CHEST-
• The breathing is mostly abdominal or abdominothoracic in
infants.
• When the diaphragm is paralyzed ,the upper part of abdomen
may be drawn in [instead of being forced out ] with each
inspiration.
• If chest movements seen to be diminished on one side that is
likely to be the side on which there is an abnormality.
• Intercostal recession ,a drawing in of the intercostal spaces
with inspiration may indicate severe upper airway obstruction
as in laryngeal disease or tumor of the trachea..

49. • The position of trachea
and apex beat-
• The trachea is examined in child
in supine position or sitting with
slight flexion of neck.
• Place the index finger into
intrasternal notch and gently
push it backward.
• Normally finger should touch the
trachea in midline ,if trachea is
deviated finger will slide into
tracheo-sternomastoid space.

50. • In a child with marked tracheal displacement ,sternocleidomastoid
becomes more prominent on side to which trachea is shifted ,it is
called ‘trail sign’.
• In normal children trachea may be slightly deviated to the right.
• Trachea may be slightly deviated to the diseased side due to
collapse ,fibrosis and thickened pleura.
• It may be pushed towards normal side by pleural
effusion,pneumothorax and a mass lesion.
• Scoliosis may cause tracheal deviation and should be excluded.

51. Palpation-
• Lymph nodes- The lymph nodes in the supra clavicular
fossa,cervical region and axillary region should be palpated.
• The lymph nodes in the neck are best felt by sitting the patient up
and examining from behind.
• Swelling and tenderness- It is useful to palpate any part of the
chest that presents an obvious swelling or where the patient
complains of pain.Feel gently ,as pressure may increase the pain.
• Feel for any abnormal vibrations eg. Rhonchi,friction rub,coarse
crackles and characteristic spongy feeling of subcutaneous
emphysemma.

52. • Vocal or tactile fremitus
is looked for by comparing
tactile transmission of
spoken words [like
one,two,three] or cry in
infants over identical areas
of two sides of the chest.
• It may be normal and equal
on two sides or decreased
or increased over a
particular area.it has the
same significance as vocal
resonance but it is
unreliable in children.

53. • Assess the expansion of
chest on two sides.

54. • If one thumb remain closure to mid line,this suggest
diminished expansion on that side.
• When pneumothorax is suspected in newborn baby and
infants,transillumination of chest can be done with a fiber
optic cold light source in a dark room, the hemi thorax will
glow with light if there is pneumothorax and decompression
can be done without delay.

55. Percussion-
• The pleximeter finger should be placed in firm contact with
the chest,while rest of the fingers should be lifted off the
chest because they may dampen the resonance.
• The pleximeter finger should move from resonant towards
possible dull area.
• The tap should be free and gentle.

57. • If organ or tissue to be
percussed is superficial, it is
advised to do light
percussion.
• For example, direct
[without pleximeter] light
percussion over the
clavicles is done to assess
the apices of the lungs.

58. • The identical areas of chest on two sides should be compared
simultaneously.
• The chest may be normally or equally resonant on two sides,
there may be unilateral or bilateral hyper resonance as in
pneumothorax, emphysema.
• Tympanitic note in large cavity, pneumothorax.
• Impaired resonance in consolidation,collapse,fibrosis.
• Dull note in consolidation, pleural thickening.

59. • Stony dull note in pleural effusion or empyema.
• Rising dullness[ higher level of dullness is axilla as compared
to front and back] and shifting dullness should be [the level of
dullness is more on lying down than on sitting up] looked for
when pleural effusion is suspected.

60. • Auscultatory percussion-
• It is more reliable and informative than the conventional
percussion and can pick up small lesions up to 3 cm in
diameter specially hilar or mediastinal
lymphnodes,pulmonary infiltrate ,atelactasis and patches
of pneumonia.
• The examiner percuss over the manubrium sterni and
listening with the diaphragm piece of stethoscope
applied snugly by the other hand over the posterior chest
wall.

62. • Auscultation-
• The infants and young
children are best
auscultated while
mother father supports
the child against the
security of their
shoulder.

63. AUSCULTATORY AREAS

64. CHARACTER OF BREATH SOUNDS

65. ADVENTITIOUS SOUNDS
A