PHYSICAL EXAMINATION

OF RESPIRATORY SYSTEM

Dr. WIDYA SRI HASTUTI, Sp.P, FCCP, FAPSR

 DR. WIDYA SRI HASTUTI, SP.P, FCCP,
FAPSR

Academic Qualification:
2004 M.D, Faculty of Medicine University of Indonesia,
Jakarta
2013 Pulmonologist, Faculty of Medicine University of
Indonesia, Jakarta
2015 Fellow of American College of Chest Physician
2015 Fellow of Asian Pasific Society of Respirology

Current Position:

Pulmonologist, Embung Fatimah Hospital, Batam

Pulmonologist, Harapan Bunda Hospital, Batam

Pulmonologist, Sanomedika Clinic, Batam

 EXAMINATION OF THE CHEST

 INSPECTION
 PALPATION
 AUSCULTATION
 PERCUSSION
 GENERAL EXAMINATION

STATIC
 General condition
 Head (edema)
 Face
 Eye ( conjungtiva, ptosis, myosis)
 Neck (JVP, trachea deviation, lymph node)
 Hand (clubbing finger)
 Foot (edema)
 Skin (cyanosis)
 GENERAL EXAMINATION

CYANOSIS
 Central
 Peripheral
causes
 COPD
 Type 2 resp. failure
 Pulmonary fibrosis
 Brochial asthma
 Congenital cyanotic heart disease
 Pulmonary embolism
 CENTRAL CYANOSIS

 Results from pulmonary dysfunction, the mucous membrane

of conjunctiva and tongue are bluish.
 If there was chronic hypoxemia and secondary erythrocytosis,
you can detect the conjunctival and scleral vessels to be full,
tortuous and bluish.
Central Cyanosis
OEDEMA
Right ventricular failure —cor pulmonale
FACE

 Pink puf fers

 Blue bloaters
 Congested neck veins
 Rashes
EYES

 Horner,s syndrome---ca. bronchus

Chemosis---SVC obstruction
---COPD
NECK
Lymph nodes----TB
---lymphoma
--sarcoidosis
---malignancy
SKIN
 Rashes—herpes zoster
 Scars---previous operation,burns , biopsies
 Pigmentation—haemochromotosis
 Dilated veins---SVC obstruction
DILATED VEINS
HANDS
 Cyanosis
 Clubbing---ca. bronchus
---TB
---empyema
---abcess
---fibrosing alveolitis
---bronchiectasis
 Wasting of small muscles of hand ---pancoast
tumour
PANCOAST TUMOR
WASTING OF SMALL MUSCLE OF
HAND
CLUBBING FINGER
 EXAMINATION OF THE CHEST

Inspection
 A-P diameter
 Tranverse diameter
 Shape of the chest
Pectus excavatum
Pectus carinatum
BARREL CHEST

AP Diameter = Transverse
Diameter
SHAPE: PECTUS EXCAVATUM
PIGEON CHEST
 KIFOSKOLIOSIS

 Click to add text

 RESPIRATORY PATTERNS

 Cheyne stokes breathing---cyclical variation in the depth of

respiration with period of apnoea.
 Kusmaull breathing
 Asthmatic breathing
 Biot’s breathing
RESPIRATORY PATTERNS
 PALPATION

Trachea
4-5 cm of the upper trachea can be felt in the
neck between the cricoid cartilage and the
sternal notch.
 Pushed –pneumothorax
-pleural effusion
 Pulled—fibrosis
--collapse
Tracheal shift to right
 Chest expansion– normal up to 5 cm
-abnormal < 2 cm
 Apex beat
 Tactile fremitus
-- Ask the patient to say 99 or 77
--you should feel the vibration transmitted through the airways
to the lung.
RIB EXCURSION/TACTILE FREMITUS
Tactile Fremitus

Increased fremitus indicates fluid in the

lung or consolidation of the underlying lung
tissue.
Decreased fremitus indicates sound
transmission obstructed by
chronic obstructive pulmonary disease
(COPD)
fluid outside the lung (pleural effusion)
air outside the lung (pneumothorax)
Movement:

Front: infraclavicular, mammary,

inframammary.
Back: scapular, infrascapular

e.g. Equal movement on both sides

or
Decreased movement on (site- {e.g.
right inframammary})
MOVEMENT:
MOVEMENT:
 CAUSES OF DECREASE OF CHEST WALL
MOVEMENTS :

Unilateral ↓ of chest wall movements:

•Pleural effusion
•Empyema
•Pneumothorax
•Pulmonary consolidation
•Pulmonary collapse
•pulmonary fibrosis

Bilateral ↓ of chest wall movements:

•Emphysema
•Bronchial asthma
•Diffuse pulmonary fibrosis
 PERCUSSION

 The percussion note loses its normal resonance when ever

aerated lung tissue is separated from the chest wall by fluid
or pleural thickening .
OR
 When lung tissue is separated from chest wall by collapse or
consolidation or fibrosis
 ANTERIOR IMAGINARY LINES AND
LANDMARKS

Suprasternal fossa Supraclavicular fossa

Infraclavicular fossa Sternal line

Parasternal line
Anterior midline

Midclavicular line
Epigastric angle
 LATERAL IMAGINARY LINES

Posterior axillary line

Anterior axillary line

Midaxillary line
POSTERIOR IMAGINARY LINES AND
LANDMARKS
Suprascapular region

Interscapular region

Infrascapular region
Scapular line

Posterior midline
 Increased in---pneumothorax
--emphysema
 Decreased---pleural effusion
AUSCULTATION
ORDER OF AUSCULTATION
 SOUND OF AUSCULTATION

1. Normal breath sound

2. Abnormal breath sound
3. Adventitious sound
 1. NORMAL BREATH SOUND
Bronchial

 Tracheal breath sound

 Bronchial breath sound Bronchovesicular
 Larynx, suprasternal fossa,
around 6th, 7th cervical
vertebra, 1st, 2nd thoracic
vertebra
 Bronchovesicular breath
sound Bronchial
 1st, 2nd intercostal space
beside of sternum, the level
of 3rd, 4th thoracic vertebra in
interscaplar area, apex of lung Bronchovesicular
 Vesicular breath sound
 Most area of lungs
Normal breath sounds: bronchial

 loud and harsh; heard

over trachea.
Abnormal when heard
elsewhere
(pneumonia, tumor).
 Normal breath sounds: Vesicular

; soft, low, heard in periphery and base of lungs.

 soft, low, heard in

periphery and base
of lungs.
Normal breath sounds:
bronchovesicular

 medium pitch,
heard between
scapula and
anteriorly close
to sternum.

Copyright © 2000 by W. B. Saunders Company. All rights reserved.

 2. ABNORMAL BREATH SOUND

 Abnormal vesicular breath sound

 Abnormal bronchial breath sound

 Abnormal bronchovesicular breath sound

ABNORMAL VESICULAR BREATH SOUND(1)

1) Decreased or disappeared
 Movement of thoracic wall
 Respiratory muscle weakness
 Obstruction of airway
 Hydrothorax or pneumothorax
 Abdominal diseases: ascites, large tumor
2) Increased
 Movement of respiration
ABNORMAL BRONCHIAL BREATH SOUND
(TUBULAR BREATH SOUND)

 Bronchial breath sound appears in supposed vesicular breath

sound area

 Consolidation: lobar pneumonia (consolidation stage)

 Large cavity: TB, lung abscess
 ABNORMAL BRONCHOVESICULAR
BREATH SOUND
 Bronchovesicular breath sound appears in supposed vesicular
breath sound area

 The lesion is relatively smaller or mixed with normal lung tissue

 3. ADVENTITIOUS SOUND

 (moist) Crackles

 Rhonchi (wheezes)

 Pleural friction rub

 MOIST CRACKLES

Mechanism
During inspiration, air flow passes thin secretion in the
airway to rupture the bubbles, or to open the collapse of
bronchioli due to adhesion by secretion.
 CLASSIFICATION OF CRACKLES

 According to intensity of the sound

1. Loud moist crackles
2. Slight moist crackles
 SITE OF CRACKLES

1. Local: local lesion

 Pneumonia, TB, bronchiectasis
2. Both bases
 Pulmo. edema, bronchopneumonia,
chronic bronchitis
3. Full fields
 Acute pulmo. edema, severe bronchopneumonia, chronic
bronchitis with severe infection
 RHONCHI (WHEEZES)

Mechanism
The turbulent flow is formed in trachea, bronchi
or bronchioli due to airway narrow or incomplete
obstruction.
Causes
 Congestion
 Secretion
 Spasme
 Tumor
 Foreign subject
 Compression
 SITE OF RHONCHI

1. Both fields
 Asthma
 Chronic bronchitis
 Acute left heart failure
2. Local site
 Tumor
 Endobronchial TB
 PLEURAL FRICTION RUB

1. Cellulose exudation in pleurisy (rough pleura)

2. Area of auscultation
 Anterolateral thoracic wall (maximal shifting area of
lung)
3. Friction rub disappeared if holding breath
4. Friction rub appeared both breath and heart beat:
mediastinal pleurisy
5. Causes
 Tuberculous pleurisy
 Pulmo. embolism
 Uremia
 Pleural mesothelioma
Added sounds
 Crepitations---fine ---heart failure
--fibrosing alveolitis
---coarse—bronchiectasis
--infections
 Wheezes or rhonchi---COPD
--bronchial asthma

Stridor is an inspiratory wheeze associated with upper airway

obstruction (croup) caused by a foreign body or possibly a
tumour.
BREATH SOUNDS
THANK YOU-WSH-