lung examination: abnormal arcot j. chandrasekhar, m.d. december 1, 2009 loyola university medical...
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Lung Examination: AbnormalLung Examination: Abnormal
Arcot J. Chandrasekhar, M.D.Arcot J. Chandrasekhar, M.D.December 1, 2009December 1, 2009
LOYOLA UNIVERSITY MEDICAL CENTER
Loyola University Chicago
Respiratory SystemRespiratory System
LungsLungs
AirwaysAirways
PleuraPleura
MediastinumMediastinum
Chest WallChest Wall
Respiratory CentersRespiratory Centers
Pathological CorrelationPathological CorrelationLocalized DiseaseLocalized Disease– ConsolidationConsolidation– CavitationCavitation– MassMass– AtelectasisAtelectasis
Pleural DiseasePleural Disease– Pleural effusionPleural effusion– PneumothoraxPneumothorax
Diffuse Lung DiseaseDiffuse Lung Disease– EmphysemaEmphysema– Diffuse airway diseaseDiffuse airway disease– Diffuse alveolar diseaseDiffuse alveolar disease– Diffuse interstitial diseaseDiffuse interstitial disease
Mediastinal DiseaseMediastinal DiseaseRespiratory CentersRespiratory Centers
Physical Exam StepsPhysical Exam Steps
General examinationGeneral examination
Mediastinal positionMediastinal position
Chest expansionChest expansion
Lung resonanceLung resonance
Breath soundsBreath sounds
Adventitious soundsAdventitious sounds
Voice transmissionVoice transmission
General ExaminationGeneral Examination
Respiratory rateRespiratory ratePattern of breathingPattern of breathingCyanosisCyanosisClubbingClubbingWeightWeightCoughCoughHospital settingHospital settingEffort of ventilationEffort of ventilationShape of thoraxShape of thorax
Respiratory RateRespiratory Rate
Bradypnea: rate less than 8 per minute Bradypnea: rate less than 8 per minute
Tachypnea: rate greater than 25 per Tachypnea: rate greater than 25 per minuteminute
Pattern of BreathingPattern of Breathing
KussmalsKussmals
Sleep apneaSleep apnea
Cheyne strokesCheyne strokes
Pursed lip breathingPursed lip breathing
Orthopnoea: Short of breath in supine Orthopnoea: Short of breath in supine position, gets some relief by sitting or position, gets some relief by sitting or standing upstanding up
Sleep apnea syndrome
Central CyanosisCentral Cyanosis
Results from pulmonary dysfunction, the Results from pulmonary dysfunction, the mucous membrane of conjunctiva and mucous membrane of conjunctiva and tongue are bluish.tongue are bluish.
If there was chronic hypoxemia and If there was chronic hypoxemia and secondary erythrocytosis, you can detect secondary erythrocytosis, you can detect the conjunctival and scleral vessels to be the conjunctival and scleral vessels to be full, tortuous and bluish.full, tortuous and bluish.
Central Cyanosis
Corpulmonale
Clubbing
ClubbingClubbing
In clubbing, there is widening of the AP and In clubbing, there is widening of the AP and lateral diameter of terminal portion of fingers and lateral diameter of terminal portion of fingers and toes giving the appearance of clubbing.toes giving the appearance of clubbing.
The angle between the nail and skin is greater The angle between the nail and skin is greater than 180than 180..The periungual skin is stretched and shiny.The periungual skin is stretched and shiny.
There is fluctuation of the nail bed.There is fluctuation of the nail bed.
One can feel the posterior edge of the nail.One can feel the posterior edge of the nail.
Significance: Clubbing Observed In:Significance: Clubbing Observed In:
Intrathoracic malignancy: Primary or Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)secondary (lung, pleural, mediastinal)
Suppurative lung disease: (lung abscess, Suppurative lung disease: (lung abscess, bronchiectasis, empyema)bronchiectasis, empyema)
Diffuse interstitial fibrosis: Alveolar Diffuse interstitial fibrosis: Alveolar capillary block syndromecapillary block syndrome
In association with other systemic In association with other systemic disordersdisorders
Gibbus
WeightWeight
Emaciation cachecticEmaciation cachectic– MalignancyMalignancy– TuberculosisTuberculosis
320 lbs
WeightWeight
Obese: Sleep apnea syndromeObese: Sleep apnea syndrome
3 Layered sputum
CoughCough
ProductiveProductive
DryDry
WhoopingWhooping
BovineBovine
2 liters of O2
Hospital SettingHospital Setting
Isolation roomIsolation room
Oxygen set upOxygen set up
Effort of VentilationEffort of Ventilation
Patient appears uncomfortable. Breathing Patient appears uncomfortable. Breathing seems voluntary.seems voluntary.Accessory muscles are in use, expiratory Accessory muscles are in use, expiratory muscles are active and expiration is not muscles are active and expiration is not passive any more.passive any more.The degree of negative pleural pressure is The degree of negative pleural pressure is high.high.The respiratory rate is increased.The respiratory rate is increased.
Resting Size and Shape of ThoraxResting Size and Shape of Thorax
Barrel chestBarrel chest
KyphosisKyphosis
ScoliosisScoliosis
Pectus excavatumPectus excavatum
GibbusGibbus
Barrel ChestBarrel Chest
AP Diameter = Transverse Diameter
Tracheal Position: MediastinumTracheal Position: Mediastinum
Any deviation of the mediastinum is abnormalAny deviation of the mediastinum is abnormal
Lateral shift: The mediastinum can be either Lateral shift: The mediastinum can be either pulled or pushed away from the lesionpulled or pushed away from the lesion– Pull: Loss of lung volume (Atelectasis, fibrosis, Pull: Loss of lung volume (Atelectasis, fibrosis,
agenesis, surgical resection, pleural fibrosis)agenesis, surgical resection, pleural fibrosis)– Push: Space occupying lesions (pleural effusion, Push: Space occupying lesions (pleural effusion,
pneumothorax, large mass lesions)pneumothorax, large mass lesions)– Mediastinal masses and thyroid tumorsMediastinal masses and thyroid tumors
Tracheal shift to right
Chest ExpansionChest Expansion
Asymmetrical chest expansion is abnormalAsymmetrical chest expansion is abnormal– The abnormal side expands less and lags The abnormal side expands less and lags
behind the normal sidebehind the normal side– Any form of unilateral lung or pleural disease Any form of unilateral lung or pleural disease
can cause asymmetry of chest expansioncan cause asymmetry of chest expansion
Global expansion decreaseGlobal expansion decrease
Percussion: Decreased or Increased Percussion: Decreased or Increased Resonance is AbnormalResonance is Abnormal
DullnessDullness– Decreased resonance is noted with pleural effusion Decreased resonance is noted with pleural effusion
and all other lung diseasesand all other lung diseases– The dullness is flat and the finger is painful to The dullness is flat and the finger is painful to
percussion with pleural effusionpercussion with pleural effusion
Hyper resonance: Increased resonance can be Hyper resonance: Increased resonance can be noted either due to lung distention as seen in noted either due to lung distention as seen in asthma, emphysema, bullous disease or due to asthma, emphysema, bullous disease or due to PneumothoraxPneumothoraxTraube's spaceTraube's space
Breath soundsBreath sounds
Breath Sounds: Diminished or Breath Sounds: Diminished or AbsentAbsent
Intensity of breath sounds, in general, is a Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.good index of ventilation of the underlying lung.Breath sounds are markedly decreased in Breath sounds are markedly decreased in emphysema.emphysema.Symmetry: If there is asymmetry in intensity, Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is the side where there is decreased intensity is abnormal.abnormal.Any form of pleural or pulmonary disease can Any form of pleural or pulmonary disease can give rise to decreased intensity.give rise to decreased intensity.Harsh or increased: If the intensity increases Harsh or increased: If the intensity increases there is more ventilation and vice versa.there is more ventilation and vice versa.
BronchialBronchial
Bronchial breathing anywhere other than over Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular the trachea, right clavicle or right inter-scapular space is abnormal.space is abnormal.In consolidation, the bronchial breathing is low In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of pitched and sticky and is termed tubular type of bronchial breathing.bronchial breathing.In cavitary disease, it is high pitched and hollow In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can and is called cavernous breathing. You can simulate this sound by blowing over an empty simulate this sound by blowing over an empty coke bottle.coke bottle.
Bronchial breathingBronchial breathing
Expiration as long as Expiration as long as inspirationinspiration
Pause between Pause between inspiration and expirationinspiration and expiration
QualityQuality
RhonchiRhonchi
Rhonchi are long continuous adventitious Rhonchi are long continuous adventitious sounds, generated by obstruction to sounds, generated by obstruction to airways.airways.When detected, note whether it is When detected, note whether it is generalized or localized, during inspiration generalized or localized, during inspiration or expiration, and the pitch.or expiration, and the pitch.Diffused rhonchi would suggest a disease Diffused rhonchi would suggest a disease with generalized airway obstruction like with generalized airway obstruction like asthma or COPD.asthma or COPD.
RhonchiRhonchi
AsthmaticContinuous
RhonchiRhonchi
Localized rhonchi suggests obstruction of any Localized rhonchi suggests obstruction of any etiology e.g., tumor, foreign body or mucous.etiology e.g., tumor, foreign body or mucous.
Mucous secretions will disappear with coughing, Mucous secretions will disappear with coughing, so would the rhonchus.so would the rhonchus.
Expiratory rhonchi implies obstruction to Expiratory rhonchi implies obstruction to intrathoracic airways.intrathoracic airways.
Asthmatics can also have inspiratory rhonchi Asthmatics can also have inspiratory rhonchi while it is uncommon in COPD.while it is uncommon in COPD.
Pleural RubPleural Rub
Normal parietal and visceral pleura glide Normal parietal and visceral pleura glide smoothly during respiration.smoothly during respiration.If the pleura is roughened due to any reason, a If the pleura is roughened due to any reason, a scratching, grating sound, related to respiration scratching, grating sound, related to respiration is heard.is heard.You can hear the sound by compressing harder You can hear the sound by compressing harder with the stethoscope and making the patient with the stethoscope and making the patient take deep breaths.take deep breaths.It is localized and can be palpable.It is localized and can be palpable.
Pleural rubPleural rub
Scratching, GratingRelated to respiration
StridorStridor
Loud audible inspiratory rhonchi is called a Loud audible inspiratory rhonchi is called a stridor.stridor.
Inspiratory rhonchi in general, implies Inspiratory rhonchi in general, implies large airway obstruction.large airway obstruction.
Stridor
Asthma
CracklesCrackles
Interrupted adventitious sounds are called crackles.Interrupted adventitious sounds are called crackles.
Make a notation about timing, intensity, effect with Make a notation about timing, intensity, effect with respiration, position, coughing and character.respiration, position, coughing and character.
Timing and Intensity Crackles heard only at the end of Timing and Intensity Crackles heard only at the end of inspiration are called fine crackles.inspiration are called fine crackles.– When the surfactant is depleted, the alveoli collapse. Air When the surfactant is depleted, the alveoli collapse. Air
enters the alveoli at the end of inspiration.enters the alveoli at the end of inspiration.– This sound is generated as the alveoli pop open from it's This sound is generated as the alveoli pop open from it's
collapsed state.collapsed state.
CracklesCrackles
When the crackles are heard at the end of When the crackles are heard at the end of inspiration and the beginning of expiration inspiration and the beginning of expiration the fluid or secretions are probably in the fluid or secretions are probably in respiratory bronchioles: medium crackles.respiratory bronchioles: medium crackles.
If the crackles are heard throughout it If the crackles are heard throughout it implies the secretions are in bronchi: implies the secretions are in bronchi: coarse crackles.coarse crackles.
Voice Transmission Voice Transmission (tactile fremitus, vocal resonance)(tactile fremitus, vocal resonance)
Asymmetrical voice transmission points to Asymmetrical voice transmission points to disease on one side.disease on one side.Increased:Increased:– Any situation where bronchial breathing is Any situation where bronchial breathing is
heard the sounds become loud, sharp and heard the sounds become loud, sharp and distinct: Bronchophony.distinct: Bronchophony.
– In extreme situations, the whispered words In extreme situations, the whispered words come clearly and distinctly: Whispering come clearly and distinctly: Whispering pectoriloquy.pectoriloquy.
Voice TransmissionVoice Transmission(tactile fremitus, vocal resonance)(tactile fremitus, vocal resonance)
Decreased: A quantitative decrease in Decreased: A quantitative decrease in voice transmission could be due to any voice transmission could be due to any other form of lung or pleural disease.other form of lung or pleural disease.Qualitative Alteration:Qualitative Alteration:– A qualitative alteration of voice transmission is A qualitative alteration of voice transmission is
noted over consolidation and along the upper noted over consolidation and along the upper margin of pleural effusion: Egophonymargin of pleural effusion: Egophony
– The sound is like a nasal twang or goat The sound is like a nasal twang or goat bleating.bleating.
Voice Transmission
Bronchophony
Whispering Pectoroliquy
Normal Whisper
Egophony