THORAX and LUNGS
Leida Marie P. Alarcon, MD, FPAFP
LEARNING OBJECTIVES
• To review the anatomy and physiology of respiratory system
• To know the anatomical landmarks in describing lesions in the chest
• To know the salient points in taking the health history of respiratory
system
• To know important topics on health promotion and counselling of
certain diseases affecting the respiratory system
• To demonstrate the proper techniques on the examination of the
chest and lungs
• To know the proper technique in recording the physical examination
of the thorax and lungs.
Anatomy and physiology
The Trachea and Major Bronchi
Health history
Chest
Pain
Wheezing
Common or Concerning Symptoms
Shortness
of breath
(dyspnea)
Cough
Hemoptysis
Health history
Chest
Pain
Wheezing
Common or
Concerning
Symptoms
Shortness
of breath
(dyspnea)
Cough
Hemoptysis
Sources of chest pain and related causes
The myocardium
Angina pectoris, myocardial infarction,
myocarditis
The pericardium
Pericarditis
The aorta
Dissecting Aortic Aneurysm
The trachea and large bronchi
Bronchitis
The parietal pleura
Pericarditis, pneumonia, pneumothorax,
pleural effusion, pulmonary embolus
The chest wall, including the musculoskeletal system and skin
Costochondritis, herpes zoster
The esophagus
Reflux esophagitis, esophageal spasm,
esophageal tear
Extrathoracic structures such as the neck, gallbladder, and stomach
Cervical arthritis, biliary colic, gastritis
Health history
Chest
Pain
Wheezing
Common or Concerning
Symptoms
Shortness
of breath
(dyspnea)
Cough
Hemoptysis
Health history
Chest
Pain
Common or Concerning Symptoms
Shortness of
Wheezing
breath
(dyspnea)
Cough
Hemoptysis
Health history
Chest
Pain
Wheezing
Common or Concerning Symptoms
Shortness of
breath (dyspnea)
Cough
Hemoptysis
Health history
Chest
Pain
Wheezing
Common or Concerning
Symptoms
Shortness
of breath
(dyspnea)
Cough
Hemoptysis
HEALTH PROMOTION AND Counseling:
Evidence and Recommendations
Tobacco Cessation
Immunizations
Adverse effects of smoking on health and disease
CONDITION
Coronary artery disease
INCREASED RISK COMPARED WITH
NONSMOKERS
2-4 times higher
Stroke
2-4 times higher
Peripheral vascular disease
10 times higher
COPD mortality
12-13 times higher
Lung Cancer Mortality
23 times higher in men
13 times higher in women
Assessing readiness to quit smoking:
Brief Intervention Models
5 As MODEL
Ask about tobacco use
Advise to quit
STAGES of CHANGE MODEL
Precontemplation- “ I don’t want to
quit”
Contemplation – “ I am concerned
but not ready to quit now”
Assess willingness to make a quit
attempt
Assist in quit attempt
Preparation- “ I am ready to quit”
Arrange follow-up
Maintenance- “ I quit 6 months ago”
Action- “ I just quit.”
Lung Cancer
• Epidemiology.
- second most frequently diagnosed cancer in the United States
and the leading cause of cancer death for both men and women.
• Risk Factors
-Cigarette smoking is by far the leading risk factor for lung cancer.
- also has a familial risk
LUNG CANCER
• Prevention.
- smoking cessation strategies.
- Avoiding environmental and occupational exposures can also reduce lung cancer risk.
• Screening.
-cancers diagnosed at an early stage (before metastasis) have a 54% 5-year
relative survival. Meanwhile, the 5-year relative survival is a dismal 4% for cancers
diagnosed at later stages (metastatic).
-only 15% of lung cancers are diagnosed at an early stage.
• Screening Tests and Evidence.
- lung cancer screening with chest x-ray or sputum cytology is not effective.
- National Lung Screening Trial (NLST) showed that screening with low-dose
computed tomography (LDCT) reduced the risk of dying from lung cancer compared
to chest x-ray screening.
Demographics of patients with COVID-19 infection
The median age of hospitalized patients varies between 47
and 73 years, with most cohorts having a male
preponderance of approximately 60%.
Incubation period
January to February 2020
showed that the median
incubation
period
was
estimated to be 5.1 days (95%
CI, 4.5-5.8 days), with almost
98% of patients manifesting
within 11.5 days (CI 8.2-15.6
days) of infection(23)
CLINICAL MANIFESTATIONS
Fever and cough were the most
common symptoms first described
among patients diagnosed with
COVID-19 infection in Wuhan,
Hubei Province, China.
The incidence of muscle
soreness
or fatigue was 42.5%
Diarrhea, hemoptysis, headache,
sore throat, shock, and other
symptoms occurred only in a small
number of patients.
• Olfactory and/or gustatory
dysfunctions have been
reported in 64% to 80% of
patients.
• Anosmia or ageusia may be
the sole presenting symptom
in approximately 3% of
individuals with COVID19(26). Anosmia or dysgeusia
may precede the respiratory
symptoms.
Clinical Course of Patients with COVID-19
• Median time from illness onset to dyspnea was 13·0 days (9·0–16·5).
• Fever and cough were prolonged, with median
duration of 12·0 days
• Notably, 62 (45%) of survivors still had cough on discharge and 39
(72%) of non-survivors had cough at the time of death.
DIAGNOSTIC TESTING
All symptomatic individuals with
suspected SARS COV-2 respiratory
tract infection should undergo
testing for COVID-19 as well as
ancillary tests warranted by their
clinical condition.
Benefits of prompt testing include:
1. Proper allocation of personal
protective equipment
2. Prevention of nosocomial spread
and
subsequent
community
transmission
3. Guidance in treatment decisions
and enrollment in clinical trials
Tests for SARS COV-2 (COVID-19)
A.
Real-time
reverse
transcription-polymerase chain
reaction (RT-PCR) assay
The currently recommended test
to confirm COVID-19 infection is
an RT-PCR assay, which detects
the viral RNA.
Using this assay, SARS CoV-2 can
be detected in nasal or
pharyngeal samples, sputum,
bronchoalveolar lavage fluid, and
other bodily fluids,
including feces and blood.
False negative results of RT-PCR assays may be due to inadequate sample
and inappropriate timing of sample collection in relation to onset symptom
RECOMMENDATIONS
• All symptomatic individuals suspected of having COVID-19
patients should undergo SARS CoV-2 RT-PCR assay testing to
diagnose COVID-19 infection.
• Nasopharyngeal specimens rather than oropharyngeal or saliva
specimens are preferred for swab-based SARS-CoV-2 testing.
• The qualitative reporting of results of SARS-COV-2 RT-PCR as
positive or negative is sufficient for DIAGNOSIS but may be
supplemented by a CYCLE THRESHOLD report.
B.) Rapid Tests based on Antigen Production
Rapid antigen test detects the presence of viral
proteins (antigens) expressed by the COVID-19 virus in
a sample from the respiratory tract of a person.
Summary of CDC influenza vaccine
recommendations 2010-adults
• Adults with chronic pulmonary conditions and chronic medical conditions; adults who are
immunosuppressed or morbidly obese
• Women who are or who will be pregnant during influenza season
• Residents of nursing homes and chronic care facilities
• Health care personnel
• Household contacts and caregivers of children 5 years of age and younger (especially infants age 6
months and younger) and of adults 50 years of age and older with medical conditions placing them at
higher risk for complications of influenza
Summary of CDC Pneumococcal vaccine
recommendations 2010
• Adults > 65 years
• Smokers from 19 years to 64 years old
• Children and adults from 2 years to 64 years old with chronic illnesses specifically associated
with increased risk of pneumococcal infection ( sickle cell anemia, cardiovascular and
pulmonary disease, diabetes, cirrhosis and leaks of cerebrospinal fluid)
• Anyone with or about to receive a cochlear implant
• Adults and children older than 2 years who are immunocompromised (including from HIV
infection, AIDS, steroids, radiation or chemotherapy)
COVID 19 VACCINE
TECHNIQUES FOR
EXAMINATION
Chest and Lungs
Physical Examination
• Correlate with History,
• Tools
•
•
•
•
Inspection
Palpation
Percussion
Auscultation
Inspection
• Observe the chest for asymmetry or
deformity. Note any scars, lesions, or
rashes.
• Observe the rate, rhythm, depth, and
effort of breathing.
• Observe the apical impulse if possible.
Chest Inspection
• Breathing - rate, rhythm, effort
• Intercostal retraction
• Shape of the thorax
• Symmetry
• Deformities
• Abnormal structures
• Mass, discoloration, sinus tract, puncture
• Inspect anterior and posterior chest
Common Chest Configuration
• Normal infant - round in cross section
• Normal adult - increase in lateral diameter
• Barrel chest - increase in AP diameter
• Funnel chest - depression in lower sternum
• Pigeon chest - anteriorly displaced sternum
• Kyphoscoliosis - curved with variable shape
Kyphoscoliosis
FUNNEL CHEST
PIGEON CHEST
Palpation
•Identify any areas of tenderness or deformity.
•Assess expansion and symmetry of the chest.
•Abnormalities - mass, sinus tract
•Tactile fremitus
Palpation
Generating lung sounds…
• Acoustic repertoire of the
respiratory system
 The thorax as a damped drum
 The airways as noise makers
Generating lung sounds…
• Lung sounds occur
within a relatively
small (compared to
the wavelength of the
sound), semirigid
enclosed space
• Sound originating
from an intrathoracic
location does not
travel in a straight
line to the chest wall
x
Palpation
Tactile Fremitus
Percussion
Percussion Technique
• Pleximeter finger
• Hyperextend middle finger
• Press distal IP joint firmly on
the chest
• Avoid contact by any other part
of the hand
• Plexor finger
• Hyperextend hand
• Partially flex middle finger
• Quick, bouncy wrist motion
Percussion Technique
• Percuss from side to side and top to bottom using the pattern shown in the
illustration. Omit the areas covered by the scapulae.
• Compare one side to the other looking for asymmetry
Percussion Technique
Resonant sounds are low
pitched, hollow sounds
heard over normal lung
tissue.
Flat or extremely dull
sounds are normally heard
over solid areas such as
bones.
Dull or thudlike sounds are normally heard over dense areas
such as the heart or liver. Dullness replaces resonance when
fluid or solid tissue replaces air-containing lung tissues, such
as occurs with pneumonia, pleural effusions, or tumors.
Hyperresonant sounds
- louder and lower pitched than resonant
sounds
- are normally heard when percussing the
chests of children and very thin adults
- diseases with lung hyperinflation (COPD,
acute asthmatic attack) and in cases with
pneumothorax.
Tympanic sounds
-are hollow, high, drumlike sounds
-normally heard over the stomach, but is not a normal
chest sound. Tympanic sounds heard over the chest
indicate excessive air in the chest, such as may occur
with pneumothorax.
Diaphragmatic Excursion
Chest Auscultation
Chest
Auscultation
Chest Auscultation
• Uses:
• Assessing air flow
• Detecting obstruction
• Identifying structural abnormalities
• Two types of sounds:
• Breath sounds
• Adventitious sounds
Chest Auscultation
Patient Positioning
Normal Lung Sounds
• Sounds heard over specific locations of a healthy
chest during breathing
 Vesicular
 Bronchovesicular
 Bronchial
 Tracheal
• “Clear lung fields” is ambiguous
Adventitious Lung Sounds
•NOT inherent to process of
NORMAL breathing, therefore
denotes underlying abnormality
“Harsh breath sounds” is
ambiguous
ACCP / ATS Classification
of Adventitious Breath Sounds
Adventitious Sounds
Pulmonary
Pleural
Discontinuous Continuous Friction Rub Click or Crunch
(Pleuritis)
(Pneumothorax,
= CRACKLES
Pneumomediastinum)
RHONCHI WHEEZE
= RALES
COARSE
FINE
Adventitious Lung Sounds
WHEEZE = Sibilant Rhonchus
Continuous
> 250 msec
Whistling, musical, expiratory
If inspiratory: more severe AO
Monophonic vs. Polyphonic
e.g. Asthma, COPD
RHONCHUS = Sonorous Rhonchus
Origin of Continuous Lung Sounds
• Interaction of
• vibrating walls
• gas flowing thru airways
on the point of closure
• Depends on velocity of gas
Generalized –
Localized
-
bronchospasm
mucosal edema
widespread secretions
mass blocking airway
Improving diagnostic acumen…
1. WHEEZE – better transmitted thru
airways than thru lung / chest wall,
therefore LISTEN OVER TRACHEA
2. FORCED EXPIRATORY MANEUVER
Adventitious Lung Sounds
COARSE CRACKLE = coarse rales
Discontinuous
< 10 msec
Short, explosive, nonmusical
Bubbling
LOUD, LOW PITCH
FINE CRACKLE
= fine rales
= crepitations
Exclusively inspiratory,
mid to late Velcro-like
SOFTER, HIGH PITCH
Timing of Discontinuous Lung Sounds
• Inspiratory
• Early : Disorders of Airways
• Late : Disorders of
Parenchyma
• Expiratory
Origin of Production of Crackles
1. BUBBLING OF GAS THRU SECRETIONS
Coarse crackles – in large airways
e.g. tracheobronchitis
Fine crackles – in smaller airways
e.g. pulmo edema
2. SUDDEN OPENING OF A SUCCESSION OF
CLOSED / COLLAPSED SMALL AIRWAYS
e.g. interstitial lung diseases
Lung Sounds Exercises
To hear
is to
Believe.
LUNG SOUNDS
• TRACHEAL SOUNDS
• VESICULAR BREATH SOUNDS
• SEVERE WHEEZING IN AN
ASTHMATIC PATIENT
• FINE CRACKLES
• COARSE CRACKLES
• DIFFUSE RHONCHI
Thank You!