EXAMINATION OF RESPIRATORY SYSTEM
EXAMINATION OF RESPIRATORY SYSTEM
AIM: To examine and assess the functional status of the respiratory system of the subject.
Requirements: Stethoscope, Measuring tape, Torch.
Procedure: Note down the name, age, sex, occupation and address of the subject.
Expose the chest of the subject, and seat him in a comfortable position.
GENERAL EXAMINATION: of the subject is done with special emphasis to dyspnoea, cyanosis, clubbing, pulse rate, and respiratory rate.
Examination of Upper Respiratory Passages
Nasal Cavities: are examined under proper light for any discharge, congestion, deviated septum, or any growth.
Throat and Pharynx: are also observed for any congestion or growth.
Examination of chest: This is done in 4 steps.
1. Trachea: Normally central, can be shifted to either side in lung diseases.
2. Form and shape of the chest: Is noted from the front, sides, back and above. Look for any asymmetry, any
bulging or depression in the chest.
Normal: Sym metrical, anteroposterior diameter less than transverse diameter
Common abnormalities seen are:
Scoliosis: Asymmetry due to lateral bending of vertebral column
Kyphosis: Forward bending of vertebral column.
Pigeon Chest: Sternum ‘projects forwards - seen in rickets.
Barrel Shaped Chest: Antero posterior diameter equal to or more than transverse diameter in chronic airway obstruction. eg: Bronchial asthma.
In all the above conditions chest movements are restricted.
3. Movements of Chest
Observe from all sideswhether chest movements are symmetrical ordiminished in any part. Observe the rate and rhythm of respiratory movements.
Normal: 12-18 per minute, regular in rhythm.
Increase in rate is called tachypnoea. Decrease in rate is bradypnoea.
PERIODIC BREATHING: is irregular breathing cycles with periods of apnoea in between. See whether the movements are thoracic, abdominal, thoraco abdominal orabdominothoracictype.
4. Look for the position of apex beat:
5. Dilated veins, Visible pulsations other than apex beat and localised prominence/depression on the chest wall/intercostal oedema
1. Using the palm palpate over the chest and see if any tenderness.
2. Position of trachea: Whether central or shifted to any side. This is assessed by placing the tips of index and ring fingers on the sternoclavicularjoints and the tip of the middle finger on the cricoid cartilage. Slowly move the middle finger downwards over the trachea to the suprasternal notch and see whether any deviation is present. Marked deviation to one side is present in fibrosis of apex of lung on same side.
3. Chest Expansion: is found out by noting the chest circumference at the end of expiration and deep inspiration, using a measuring tape at the level of 4th intercostal space. Normal value is 5-8cm.
4. Apex Beat: is located by palpating with the palm of hand first, then with the ulnar border of palm and finally with the index finger. Normally located in the 5th left intercostal space 1 cm medial to the midclavicular line. Apex beat is the lowermost and outermost point over the precordium, where a definite cardiac impulse can be seen or felt. Shift in position of apex beat can occur in conditions like pleural effusion, pneumothorax. In dextrocardia, it is felt on the right side.
5. Movements of chest
Place the two palms on either side of the anterior chest wall and the tips of the thumbs are allowed to meet in the midline. Ask the subject to take a deep inspiration and observe the distance to which the tips of the thumbs move from the midline. See whether the movements are equal on both sides. Repeat the procedure on the posterior chest wall also. Underlying lung diseases can diminish the expansion at a particular area or areas.
6. Vocal Fremitus
The sound vibrations produced during phonation, transmitted through the lungs can be felt in the palm placed over the chestwall. This is tested while the subject repeats the words “one one one” in a whispering voice. Compare vocal fremitus on corresponding areas on both sides of chest. It is decreased in pleural thickening, fibrosis of the lung, pleural effusion etc. It is increased over areas of consolidation and cavities in the lung.
PERCUSSION: is the method by which the consistency of the underlying tissue is assessed by listening to the percussion note emitted from the area.
To do this, the middle finger of the left hand [pleximeter finger] is placed firm lyon the chest wall and the middle phalanx of the pleximeter finger is tapped with the middle finger of the right hand [plexorifinger], and during tapping the movement should take place at the right wrist joint only.
Rules of percussion:
The pleximeter finger should be placed parallel to the border of the organ to be percussed and the line of percussion should be perpendicularto the border to be percussed. The pleximeterfinger should be placed firmly over the body surface and there should not be air in between the finger and the body surface. Percussion should always be done from a resonant to a dull area and not in the reverse direction. During percussion the movement should take place at the wrist joint only. Over clavicular area, percussion is done directly over the clavicle.
Percussion is done over corresponding areas i.e. Supraclavicular, on the clavicle, infraclavicular, mam mary, axillary, infra axillary, suprascapular, interscapular and infrascapular on both sides and note whether the percussion notes are equal on corresponding areas. While percussing on the back, ask the subject to keep his hands on the opposite shoulders and while percussing the axillary area ask him to keep his hands over the head. The upper border of the liver and the heart borders should be percussed.
Resonant note - heard over the normal lung
Hyperresonant note - heard over air cavities [Tym panic note over the stomach]
Impaired note - heard overthefibrosed lung
Dull note - heard over consolidation, tumour
Stony dullness - heard over pleural effusion
In auscultation of the respiratory system the following points should be stressed.
Breath sounds, Additional sounds, Abnormal sounds; Vocal resonance.
Breath sounds: Normally vesicular breathing [inspiration and early part of expiration heard without any pause in between] is heard in the periphery and bronchovesicular breathing is heard towards central areas. Bronchial breathing [expiration longer than in vesicular breathing with a pause in between inspiration and expiration] is heard normally overtrachea and in disease it can be heard anywhere.
- High pitched [tubular], is heard over an area of consolidation.
- Low pitched [Cavernous], is heard over an area of cavitation in the lung.
Added sounds: are rhonchi and crepitations. Rhonchi or wheeze are dry sounds produced at the level of the bronchi and bronchioles. Rales or Crepitations are moist sounds produced at the level of the alveoli.
Pleural rub: They are discontinuous “creeky” noise heard during the middle of inspiration and expiration, due to rubbing of the inflamed pleural surfaces seen in dry pleurisy.
Pericardial rub: Heard in pericarditis and has got the cardiac rhythm to differentiate it from pleural rub.
Vocal resonance: This is the vibration of the vocal cords transmitted to the periphery of the lungs which is audible. Ask the subject to repeat one, one, one in a whispering voice and auscultate the corresponding areas one by one on both sides for vocal resonance. The diseases which favour transmission of sound will show an increase in vocal resonance on the overlying area and vice versa. For e.g. vocal resonance is increased over an area of consolidation or cavitation and decreased over an area of fibrosis or pleural effusion.