1. Inspection
- General Appearance:
- Signs of Distress: Look for tachypnea, use of accessory muscles (sternocleidomastoid, scalene, intercostals), and intercostal retractions.
- Facial Expressions and Speech: Observe for any grimacing, nasal flaring, and the ability to speak in full sentences.
- Breathing Pattern:
- Rate: Normal respiratory rate is 12-20 breaths per minute for adults. Count for 60 seconds.
- Rhythm: Regular or irregular breathing patterns.
- Depth: Observe if breaths are shallow, deep, or normal.
- Effort: Note any visible effort in breathing, like use of accessory muscles.
- Chest Shape and Movement:
- Symmetry: Both sides should rise and fall equally.
- Deformities: Barrel chest (often seen in COPD), pectus excavatum (sunken chest), or kyphoscoliosis (combined kyphosis and scoliosis).
- Skin and Nails:
- Cyanosis: Central cyanosis (lips, tongue) indicates hypoxemia; peripheral cyanosis (fingers, toes) suggests poor circulation.
- Clubbing: Bulbous enlargement of the fingertips, associated with chronic hypoxia (e.g., in lung cancer, cystic fibrosis).
- Pallor: Indicates anemia or shock.
- Scars and Deformities:
- Surgical Scars:bNote thoracotomy scars (indicative of past surgery), chest tubes.
- Deformities: Structural abnormalities like scoliosis.
- Posture:
- Tripod Position: Indicative of severe respiratory distress, commonly seen in COPD patients.
2. Palpation
- Chest Expansion:
- Technique: Place hands on the lower posterior chest, thumbs at the level of the 10th rib, fingers parallel to the ribs. Ask the patient to take a deep breath and observe the movement of your thumbs. Normal expansion is 3-5 cm symmetrically.
- Tactile Fremitus:
- Technique: Use the ulnar edge of your hands or fingertips to feel for vibrations while the patient repeats "ninety-nine" or "blue moon." Compare symmetrical areas on both sides of the chest.
- Findings: Increased fremitus suggests consolidation (e.g., pneumonia), decreased fremitus suggests pleural effusion or pneumothorax.
- Tracheal Position:
- Technique: Gently palpate the trachea in the suprasternal notch. It should be midline.
- Deviation: Tracheal deviation may indicate mediastinal shift due to tension pneumothorax or large pleural effusion.
3. Percussion
- Technique:
- Use the middle finger (pleximeter) of your non-dominant hand placed firmly against the chest wall. Strike the middle phalanx with the tip of the middle finger (plexor) of your dominant hand.
- Percussion Notes:
- Resonant: Normal lung tissue.
- Dull: Over fluid or solid tissue (e.g., consolidation, pleural effusion, tumor).
- Hyperresonant: Over areas with excess air (e.g., pneumothorax, emphysema).
- Comparative Percussion:
- Percuss from the top of the chest down, comparing symmetrical areas to identify abnormalities.
4. Auscultation
- Technique:
- Use the diaphragm of the stethoscope for high-pitched sounds. Place it firmly on the chest wall.
- Ask the patient to breathe deeply through their mouth.
- Listen systematically: posterior chest (superior to inferior), lateral chest, anterior chest.
- Breath Sounds:
- Vesicular: Soft, low-pitched, heard over most lung fields.
- Bronchial: Loud, high-pitched, heard over the trachea and large bronchi.
- Bronchovesicular: Intermediate intensity and pitch, heard over the major bronchi.
- Adventitious Sounds:
- Crackles (Rales): Discontinuous, heard in conditions like pneumonia, pulmonary fibrosis.
- Wheezes: Continuous, musical sounds, indicating narrowed airways (e.g., asthma, COPD).
- Rhonchi: Low-pitched, snore-like sounds, suggesting secretions in large airways.
- Pleural Rub: Grating sound due to pleural inflammation.
- Vocal Resonance:
- Bronchophony:Ask the patient to say "ninety-nine." Increased clarity suggests consolidation.
- Egophony: Ask the patient to say "E." If it sounds like "A," it suggests consolidation.
- Whispered Pectoriloquy: Whispered "ninety-nine" is heard clearly over areas of consolidation.
A Case Study
55-year-old male, chronic smoker, presenting with shortness of breath, cough, and fever.
Inspection:
- Appearance: Mild cyanosis on lips.
- Breathing Pattern: Tachypnea, using accessory muscles.
- Chest Shape: Normal shape but reduced movement on the right side.
- Nails: Clubbing present.
- Posture: Leaning forward, in mild distress.
Palpation:
- Chest Expansion: Reduced on the right lower chest.
- Tactile Fremitus: Increased on the right lower chest.
- Trachea: Midline.
Percussion:
-Findings: Dullness over the right lower lung field.
Auscultation:
- Breath Sounds: Decreased breath sounds in the right lower lung field.
- Adventitious Sounds: Crackles present in the right lower lung field.
- Vocal Resonance: Positive bronchophony and egophony in the right lower lung field.
Diagnosis:
Likely right lower lobe pneumonia. Further investigations like a chest X-ray and sputum culture are needed.
Major Diseases of the Respiratory System
1. Chronic Obstructive Pulmonary Disease (COPD):
- Pathophysiology: Chronic inflammation leads to airflow limitation.
- Clinical Features: Chronic cough, sputum production, dyspnea.
2. Asthma:
- Pathophysiology: Reversible airway obstruction due to bronchospasm, inflammation, and mucus.
- Clinical Features: Wheezing, shortness of breath, chest tightness, cough.
3. Pneumonia:
- Pathophysiology: Infection causing alveolar inflammation and consolidation.
- Clinical Features: Fever, productive cough, pleuritic chest pain, dyspnea.
4. Tuberculosis:
- Pathophysiology: Mycobacterium tuberculosis infection leading to granuloma formation.
- Clinical Features: Chronic cough, hemoptysis, night sweats, weight loss.
5. Lung Cancer:
- Pathophysiology: Malignant transformation of lung tissue.
- Clinical Features: Persistent cough, weight loss, hemoptysis, chest pain.
6. Pulmonary Fibrosis:
- Pathophysiology: Chronic inflammation and scarring of lung tissue.
- Clinical Features: Progressive dyspnea, dry cough, digital clubbing.
7. Pleural Effusion:
- Pathophysiology: Accumulation of fluid in the pleural space.
- Clinical Features: Dyspnea, pleuritic chest pain, decreased breath sounds.
Types of Breathing
1. Eupnea: Normal, unlabored breathing.
2. Tachypnea: Rapid, shallow breathing.
3. Bradypnea: Abnormally slow breathing.
4. Hyperpnea: Increased depth and rate of breathing.
5. Hypopnea: Reduced depth of breathing.
6. Dyspnea: Subjective feeling of difficult or labored breathing.
7. Orthopnea: Difficulty breathing while lying flat.
8. Paroxysmal Nocturnal Dyspnea: Sudden shortness of breath at night, typically waking the patient.
9. Cheyne-Stokes Respiration: Cyclic pattern of gradual increase in depth followed by a decrease and apnea.
10. Kussmaul Breathing: Deep, labored breathing often associated with diabetic ketoacidosis.
11. Apnea: Absence of breathing.
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