Lung Examination: Abnormal - Identifying Respiratory Issues through Clinical Signs, Lecture notes of Voice

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Lung Examination: Abnormal

Arcot J. Chandrasekhar, M.D.

Illustrative Pathological problems

• Consolidation
• Atelectasis
• Pleural effusion
• Pneumothorax
• Mass
• Diffuse lung disease

Steps

• General Examination
• Mediastinal position
• Chest expansion
• Lung resonance
• Breath sounds
• Adventitious sounds
• Voice transmission

General Examination

• Respiratory rate
• Pattern of breathing
• Cyanosis
• Clubbing
• Weight
• Cough
• Hospital setting
• Effort of ventilation
• Shape of thorax

Respiratory Rate

• Bradypnea: rate less than 8 per minute
• Tachypnea: rate greater than 25 per minute

Pattern of Breathing

• Kussmals
• Sleep apnea
• Cheyne strokes
• Pursed lip breathing
• Orthopnoea: Short of breath in supine

position, gets some relief by sitting or

standing up.

Corpulmonale

Clubbing

Clubbing

• In clubbing, there is widening of the AP and lateral diameter of terminal portion of fingers and toes giving the appearance of clubbing.
• The angle between the nail and skin is greater than 180 (.
• The periungual skin is stretched and shiny.
• There is fluctuation of the nail bed.
• One can feel the posterior edge of the nail.

Significance: Clubbing Observed In:

• Intrathoracic malignancy: Primary or

secondary (lung, pleural, mediastinal)

• Suppurative lung disease: (lung abscess,

bronchiectasis, empyema)

• Diffuse interstitial fibrosis: Alveolar

capillary block syndrome

• In association with other systemic disorders

Gibbus

Weight

• Emaciation cachectic
  • Malignancy
  • Tuberculosis

Cough

• Productive
• Dry
• Whooping
• Bovine

2 liters of O

Hospital Setting

• Isolation room
• Oxygen set up

Effort of Ventilation

• Person appears uncomfortable. Breathing

seems voluntary.

• Accessory muscles are in use, expiratory

muscles are active and expiration is not

passive any more.

• The degree of negative pleural pressure is

high.

• The respiratory rate is increased.

Resting Size and Shape of Thorax

• Barrel chest
• Kyphosis
• Scoliosis
• Pectus excavatum
• Gibbus

Barrel Chest

AP Diameter = Transverse Diameter

Percussion: Decreased or Increased

Resonance is Abnormal

• Dullness
  • Decreased resonance is noted with pleural effusion and all other lung diseases
  • The dullness is flat and the finger is painful to percussion with pleural effusion
• Hyper resonance: Increased resonance can be noted either due to lung distention as seen in asthma, emphysema, bullous disease or due to Pneumothorax
• Traube's space
• Breath sounds

Breath Sounds: Diminished or Absent

• Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.
• Breath sounds are markedly decreased in emphysema.
• Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal.
• Any form of pleural or pulmonary disease can give rise to decreased intensity.
• Harsh or increased: If the intensity increases there is more ventilation and vice versa.

Bronchial

• Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular space is abnormal.
• In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing.
• In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle.

Bronchial breathing

Quality

Pause between inspiration and expiration

Expiration as long as inspiration

Rhonchi

• Rhonchi are long continuous adventitious

sounds, generated by obstruction to airways.

• When detected, note whether it is

generalized or localized, during inspiration

or expiration, and the pitch.

• Diffused rhonchi would suggest a disease

with generalized airway obstruction like

asthma or COPD.

Pleural rub

Scratching, Grating Related to respiration

Stridor

• Loud audible inspiratory rhonchi is called a

stridor.

• Inspiratory rhonchi in general, implies large

airway obstruction.

Stridor

Asthma

Crackles

• Interrupted adventitious sounds are called crackles.
• Make a notation about timing, intensity, effect with respiration, position, coughing and character.
• Timing and Intensity Crackles heard only at the end of inspiration are called fine crackles. - When the surfactant is depleted, the alveoli collapse. Air enters the alveoli at the end of inspiration. - This sound is generated as the alveoli pop open from it's collapsed state.

Crackles

• When the crackles are heard at the end of

inspiration and the beginning of expiration

the fluid or secretions are probably in

respiratory bronchioles: medium crackles.

• If the crackles are heard throughout it

implies the secretions are in bronchi: coarse

crackles.

Voice Transmission (tactile fremitus,

vocal resonance)

• Asymmetrical voice transmission points to

disease on one side.

• Increased:
  • Any situation where bronchial breathing is heard the sounds become loud, sharp and distinct: Bronchophony.
  • In extreme situations, the whispered words come clearly and distinctly: Whispering pectoriloquy.