This document provides an overview of the anatomy and physiology of the respiratory system. It discusses the structure of the lungs including lobes and fissures. It describes the trachea and bronchi. It explains the mechanics of breathing including inspiration and expiration. It discusses how to assess common respiratory symptoms like cough, wheezing, shortness of breath, and hemoptysis through patient history. It outlines the examination of the respiratory system including inspection, palpation, percussion, and auscultation of the chest. Adventitious breath sounds like rales, rhonchi, and wheezes are also described.

1. RESPIRATORY SYSTEM
DR. LAKITHA RATHNAWEERA

2. Anatomy &
Physiology

6. • Can describe local findings on chest on two dimensions.
- along the vertical axis
- around the circumference of the chest
• To make vertical locations, count the ribs and interspaces. Sternal angle is
the best guide!
• To locate findings around circumference of chest, imagine a series of vertical
lines around the chest wall.

9. Lungs, Fissures & Lobes
• Each lung divided (roughly) in half by an oblique (major) fissure.
• Right lung is further divided by the horizontal (minor) fissure.
• These fissures divide lungs into lobes.
- the right lung is divided into upper, middle and lower lobes.
- the left lung is divided into upper and lower lobes.
• Lung base at 6-8 ribs. T10 spinous process posteriorly.

12. The Trachea & Bronchi
• The Trachea and Major Bronchi:
- The trachea bifurcates into its mainstem bronchi at the levels of
sternal angle anteriorly and the T4 spinous process posteriorly.
• The Pleurae:
- The pleurae are serous membranes that cover the outer surface
of each lung (visceral pleura) and also the inner rib cage and
upper surface of the diaphragm (parietal pleura)
- Pleural fluids lubricate the surfaces.

16. Breathing..
• Inspiration:
- Diaphragm goes down  expands thoracic cavity  pushout
abdominal wall
- Intrathoracic pressure increases
- Scalenus and Parasternal muscles.
• Expiration:
- Chest walls and lungs recoil.
- Diaphragm relaxes  rise passively
- Chest and abdomen return to their resting position.

17. The Health History
• CHEST PAIN:
- Initially go for broad questions.
“do you have any discomfort or unpleasant feelings in your chest?”
- Ask the patient to point to the location of chest.
- Attempt to elicit all 7 attributes of pain.
- Aside from lung condition, pain may arise from cardiac, vascular,
gastrointestinal, musculoskeletal or skin pathology. It’s also
commonly associated with anxiety.

19. - Lung tissue itself has no pain fibers. Pain in lung conditions usually
arises from inflammation of the adjacent parietal pleura.
- Other surrounding structures may also irritate the parietal pleura,
causing pain.
Cardiac chest pain:
-Angina pectoris
-Myocardial Infarction
-Pericarditis
-Aortic aneurysm etc
Pulmonary chest pain:
-Tracheobronchitis
-Pleuritic chest pain

20. Gastrointestinal & Other chest pains:
-GORD
-Oesophageal spasms
-Chest wall pains
-Costochondritis
-Anxiety
• If can finger point (finger on tender areas of chest wall) mostly musculoskeletal pain.
• Epigastric area to neck pain: mostly GI related
• Most common in children: due to anxiety and costochondritis.
• Respiratory pain: If pain on breathing: mostly maybe due to a respiratory obstruction.
• Physical pain (Cardiac pain): pain with associated symptoms.

22. • Shortness of Breath (Dyspnoea/ SOB)
- Dyspnoea is a non-painful, but unpleasant, uncomfortable awareness
of breathing that is inappropriate to the level of exertion.
- Begin assessment with a broad question, such as,
“Have you had any difficulty in breathing?”
- Determine the severity of dyspnoea, based on the patients daily
activities.
• Causes may include – Left heart failure, Chronic bronchitis, COPD, BA,
Pneumonia, Spontaneous pneumothorax, Acute PE, Anxiety, Hyperventilation.

23. • Wheezing:
- Wheezes are musical respiratory sounds that may be audible to
patient and to others. It may sometimes be cardiovascular in origin.
• Cough:
- Cough is typically a reflex response to stimuli, that irritate receptors in larynx,
trachea or large bronchi. It may sometimes be CV in origin.
- Ask whether cough is dry or productive? (produces sputum or phlegm)
- Ask the patient to describe any volume of sputum, its colour, odor
and consistency. COUGH CAN BE A SYMPTOM OF LV FAILURE.

24. • Causes may include mucus, pus, blood, dust, foreign agents, extreme hot or
cold air, inflammation of respiratory mucosa, pressure or tension in airways.
ACUTE COUGH: less than 3 weeks
: viral URTI, acute bronchitis, pneumonia, LV failure,
foreign body, asthma.
SUB-ACUTE COUGH: 3 to 8 weeks
: bacterial sinusitis, asthma.
CHRONIC COUGH: more than 8 weeks
: postnasal drip, gastro-oesophageal reflux, chronic
bronchitis, bronchiectasis

25. • Mucoid sputum: translucent, white or gray
• Purulent sputum: yellow or greenish (in bronchiectasis, lung abscess)
• Foul smelling sputum: anaerobic lung abscess
• Tenacious sputum: Cystic fibrosis
• Haemoptysis:
- Haemoptysis is coughing up blood from lungs. It may vary from blood streaked
phlegm to frank blood. Rare in infants & children. Common in CF.
- Ask the patient to describe the blood volume produces and other sputum
attributes as well.
- Try to confirm the source of bleeding by history and examination,
before using the term “Haemoptysis”

26. - Blood may also originate from mouth, pharynx and GI tract.
- Stomach blood is darker than respiratory blood.
• Acute inflammations may cause hemoptysis.. Like,
- Laryngitis (dry cough)
- Tracheo-bronchitis (dry cough)
- Mycoplasma and viral pneumonias (dry cough)
- Bacterial pneumonia (pinkish red jelly – pneumococcal, klebsiella)
• Chronic inflammations may also cause hemoptysis.. Like,
- Postnasal drip (chronic cough, mucoid)
- Chronic bronchitis (chronic cough, purulent bloody)
- Bronchiectasis (chronic cough, purulent foul bloody)
- Pulmonary TB (chronic cough, purulent bloody)
- Lung abscess (chronic cough, purulent foul bloody)
- Asthma (chronic cough, mucoid)
- Gastro-oesophageal reflux (chronic cough in night and morning)

27. Lung cancer – cough, bloody sputum (starts with ?rusty colour)
LV failure, MS – dry cough, pink frothy sputum, pulmonary oedema, frank haemoptysis
Pulmonary emboli – dry cough, dark or bright red sputum
Tobacco Cessation:
- Smoking is a leading cause of preventable deaths in world.
- Remember the five “A” s
- Ask about smoking at each visit.
- Advice regularly to stop smoking.
- Assess patient’s readiness to quit.
- Assist patient to set stop dates and on education.
- Arrange follow-up visits to monitor and support progress.

30. Examination
General Techniques:
• Examine the posterior thorax and lungs while patient is sitting.
• Examine the anterior thorax and lungs while patient is supine.
• Compare one side of the thorax and lungs with the other. So the patient
serves as his or her own control.
• Proceed in an orderly fashion:
• Inspect, Palpate, Percuss and Auscultate.

31. Initial Survey of Respiration & Thorax:
• Healthy resting adult breaths 14-20/min
• Observe the rate, rhythm, depth and effort of breathing.
• Inspect for any signs of respiratory difficulties:
- Assess patients colour (for cyanosis)
- Listen patients breathing (audible stridor/wheeze may suggest URT obstruct)
- Inspect the patients neck (use of accessory muscles may suggest COPD)
- Observe the shape of chest (increased AP diameter may suggest COPD)

32. Examine the Posterior Chest:
Inspection: Note the shape of the chest and the way it moves.
Asymmetry  Pleural Effusion
Retraction  Asthma, COPD, upper airway obstruction
Unilateral impairment or lag  pleural disease from asbestosis, silicosis, phrenic nerve
damage, trauma.
Palpation:
- Identify any tender areas.
- Assess any visible abnormalities (tracheal deviation etc)
- Test chest expansion (lung excursion test) : place thumbs at the level of 10th
rib with fingers grasping loosely, and parallel to the lateral rib cage.

36. • Ask patient to take a deep breath  watch the distance between thumbs as they move
apart during inspiration.
• Unilateral decrease or delay in expansion maybe due to chronic fibrosis, pleural effusion,
lobar pneumonia etc.
Tactile Fremitus:
- palpable vibrations through broncho-pulmonary tree to chest wall
as patient is speaking.
- ask patient to repeat words “ninety nine” or “one one one”
- decreased fremitus (decrease sound transmission) in unilateral pleural effusion,
pneumothorax, emphysema and neoplasms.
- increased fremitus (increase sound transmission) in consolidations, fluid, mass,
unilateral pneumonia

37. Palpate and compare symmetric areas!

38. Percussion:
- Useful for 2 purposes: to compare and for topography (lung borders).
- Perform from side to side for comparison. Assess for asymmetry.
- Strike using the tip of your tapping finger.
- Use the lightest percussion that produces a clear note.
- Percussion helps to establish whether underlying tissues (5-7cm deep) are
air-filled, fluid-filled or solid.
- Get used to percussion notes: Flat, Dull, Resonant, Hyper-resonant and Tympanic.
- The heart normally produces an area of dullness to the left of the sternum;
from 3rd to 5th rib interspaces.

39. - Estimate the extent of diaphragmatic
excursion.
- Dullness replace resonance when, fluid or
solid tissue replaces air filled cavities!
- in lobar pn. alveoli fills with fluid and
blood
- in pleural effusion acc. of serous fluid
- in haemothorax blood
- in empyema pus etc.
- High diaphragm in Atelectasis and Phrenic
nerve paralysis.

43. Auscultation:
- Most important examination of thorax to assess the airflow through tracheobronchial
tree. We should lidten to 3 types of sounds.
- breathing (lungs) sounds
- adventitious (added) sounds
- transmitted voice sounds
- Together with percussion, it also helps to assess the condition of surrounding lung
tissues and pleural space.
- Listen to the breath sounds with a diaphragm of stethoscope, after instructing
patient to breathe deeply from an open mouth.
- Use the same pattern suggested for percussion, moving side to side, comparing
asymmetric sides of lungs.
- Listen to at least one full breath on each location.

44. Normal (lung) breath sounds:
Vesicular – soft and low pitches, usually heard over most of both lungs.
Bronchial – louder and higher in pitch, usually heard over the manubrium.
Bronchovesicular – intermediate intensity and pitch, usually heard over the 1st, 2nd ICS.
Adventitious (added) breath sounds:
Crackles – aka rales. discontinuous, intermittent non musical
- loud, low pitches, brief
- in bronchitis, pneumonia, fibrosis, left heart failure.

46. Wheezes - continuous, prolonged, musical
- high pitched, hissing or shrill quality
- due to narrowed airways (asthma, bronchitis, COPD)
Rhonchii - continuous, prolonged, musical
- low pitches, snoring quality
- due to secretions in large airways
Pleural Rub - aka friction rub.
- ask to cough, crackles stop when coughing. But pleural rub never stops
with cough, and pain of rub differs with position.
Mediastinal Crunch (Hammen’s Sign)
- When air is present in mediastinum.
- Scratchy sounds (Hammens sign) occurs
- Occur most frequently during systole.
- Common after cardiac post-op

48. Transmitted Voice Sounds:
- Only if you hear abnormally located bronchial or bronchovesicular sound,
ask pt to say “ee”
- increased transmission of voice sound (louder voice) in airless lungs and
suggests consolidation (known as bronchophony)
- if voice become nasal quality or when “ee” sounds like “aa”
scenario knowns as egophony.
Examination of the Anterior Chest:
- As examination of the posterior chest, proceed in an orderly fashion:
inspection, palpation, percussion and auscultation.
- With percussion of anterior chest, heart normally produces an area
of dullness to the left of the sternum; from 3rd to 5th rib interspaces.
- Supraclavicular retraction is normally present.

54. CHEST X RAY (CXR) Check for..
A – airways
B – basal lungs & pleura
C – cardio mediastinum
D – disabilities (visible fractures etc)
E – everything else
• R > L diaphragm gap (not more than 3cm)
• Cardiothoracic ratio not more than <55%
• Trachea diameter < 25mm in males/ < 21mm in females.
• Aortic notch should be visible.
• Any gastric abnormalities (bubbles)

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