Lung Examination: AbnormalLung Examination: AbnormalArcot J. Chandrasekhar, M.D.Arcot J. Chandrasekhar, M.D.

December 1, 2009December 1, 2009

LOYOLA UNIVERSITY MEDICAL CENTER

Loyola University Chicago

Respiratory SystemRespiratory System

LungsLungsAirwaysAirwaysPleuraPleuraMediastinumMediastinumChest WallChest WallRespiratory 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 examinationMediastinal positionMediastinal positionChest expansionChest expansionLung resonanceLung resonanceBreath soundsBreath soundsAdventitious soundsAdventitious soundsVoice transmissionVoice transmission

General ExaminationGeneral ExaminationRespiratory 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

KussmalsKussmalsSleep apneaSleep apneaCheyne strokesCheyne strokesPursed lip breathingPursed lip breathingOrthopnoea: 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 syndromeIn 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

ProductiveProductiveDryDryWhoopingWhoopingBovineBovine

2 liters of O2

Hospital SettingHospital Setting

Isolation roomIsolation roomOxygen 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 chestKyphosisKyphosisScoliosisScoliosisPectus excavatumPectus excavatumGibbusGibbus

Barrel ChestBarrel Chest

AP Diameter = Transverse Diameter

Tracheal Position: MediastinumTracheal Position: Mediastinum

Any deviation of the mediastinum is abnormalAny deviation of the mediastinum is abnormalLateral 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 effusionHyper 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 good Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.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

CracklesCracklesInterrupted 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