Student Bedside Medicine
Respiratory
Case
A young man wonders about his chest
Inspection
Pectus Excavatum
Pectus excavatum
“funnel chest”: oval pit near the infrasternal
notch or a more extensive concavity
Isolated, Noonan, Marfan, rickets,
tracheomalacia, bronchomalacia, congenital
heart disease (including mitral valve
prolapse)
Case
A young man with an abnormal sternum.
Sternum protrudes from a
narrowed thorax.
Isolated, familial, Marfan, Noonan,
rickets, acromegaly, anomalies of
the diaphragm.
Pectus carinatum “pigeon breast”
Palpation
Lung Expansion
The diseased
side moves less
well than the less
diseased.
Fremitus
German: “neun und neunzig”.
The “eu” diphthong was important - not
the number “99” we are taught!
We need English sounds with “eu” like
“toy” or “boy”.
Press entire base of palm and fingertips
against the chest to feel vibrations.
Fremitus
“toy” or “boy”
Increased
Consolidation
or mass with an
open airway.
Decreased
Obstructed
airway, pleural
effusion, pleural
scar,
pneumothorax
Chest Percussion
Leopold Auenbrugger - Austria
Wine-cask fullness
1761 Latin treatise on percussion
with four fingers of one hand to
detect pleural effusion, which was
ignored.
Chest Percussion
50 years later the work was
“rediscovered” by Corvisart
(Napoleon’s physician) who
made direct percussion a
widely popular exam
maneuver.
Indirect percussion
1828
Special hammers and
plates were developed.
As equipment was lost,
physicians used their
fingers.
Flat part of reflex hammer
is often better than the
finger of the other hand.
Percussion notes
Clinically important ones!
Dull - Medium pitch/intensity
Resonant - Low pitch, loud
Hyperresonant/tympanitic - Lowest
pitch, louder
Indirect percussion
Sides of posterior chest are
compared.
Primarily intended to screen
for pleural effusion.
Mass/consolidation may be
detected.
Pt needs to be sitting up
Dull
Resonant
Tympanitic
Auscultatory Percussion
Described soon after the stethoscope was
invented and popularized over the years
for various organs.
Sound is generated by fingers (tapping,
flicking, scratching) and detected with
stethoscope; sound changes pitch and
loudness as it moves over density
boundaries
Auscultatory Percussion
Stethoscope at lowest rib.
Light tap or flick from
above down.
Sound gets louder and
higher pitched right near
stethoscope. With pleural
effusion, sound change
occurs higher.
Easier than indirect
percussion and possible on
more frail patients.
Auscultatory Percussion
Sensitivity = 96%, Specificity
= 100% for pleural effusion
in one study. Superior to
indirect percussion.
False positives = elevated
diaphragm.
False negatives = small
effusions in patients
recumbant for hours.
Sound change
over effusion
Rene Laennec
Summer, 1816: saw children
tapping on ends of a log
and listening at each end.
Next day, rolled a notebook
of paper up into a cylinder
to listen to a woman’s chest.
Heard the heart and lungs
better than ever.
Rene Laennec
Began to experiment
with materials and
dimensions to
optimize the
listening.
Settled on a wooden
cylinder 1 foot long
and 1.5 in. in
diameter.
Rene Laennec
Three years of research resulted in “De
l’Auscultation Mediate”. He coined the term
“stethoscope” (inspector of the chest).
Known as a “cylindromaniac” and was
opposed strongly by the “percussionists” Corvisart.
It took many years before the percussionists
accepted ascultation.
Lung Anatomy
The reason why we must
examine the posterior,
lateral, and anterior chest.
Can actually do it all from
behind by going under
the lifted arm.
Lung Sounds
Breath sounds are what we hear with
our native ears as patient is breathing
through the nose and mouth.
Lung sounds are what we hear with the
stethoscope and is the preferred
terminology for describing the exam.
Decreased Lung Sounds
Diffusely decreased
Poor effort, thick chest, diffuse
obstructive or restrictive disease
Locally decreased
Local airway obstruction, effusion,
mass, pneumothorax
Vesicular Lung Sounds
Soft, rustling, 3:1 inspiration to expiration
ratio.
These are the “normal lung sounds” heard
over most of the lung periphery.
3
1
Bronchial Lung Sounds
Bronchial, tracheal, tubular lung sounds.
Louder, higher pitched, and prominent
expiration.
Heard anteriorly in normals over the
trachea/main stem bronchi.
1
3
1
1
Bronchial Sounds
Should only be heard in the upper,
anterior, central chest in patients.
Bronchial lung sounds heard anywhere
else (where vesicular should be heard) are
a sign of consolidation with an open
airway.
Adventitious Sounds
Laennec heard and named various
abnormal sounds which were later called
“adventitious”.
He called most of these some form of
“rale” - French for “rattle”.
Adventitious Sounds
Laennec could not use the term rale at
the bedside.
It reminded patients of the phrase “le
rale de la mort” (the death rattle) and
made him unpopular with the patient
and family!
Tuberculosis was rampant and Laennec
died of TB in 1826 at the age of 45.
Adventitious Sounds
Laennec developed a synonym for rales:
rhonchus.
Rhoncus in Latin meant “rattle” and in
Greek meant “snoring” and patients and
families did not know what it meant.
However, the English who studied
Laennec’s work didn’t know what these
terms meant either and they got
everything confused.
Further Term Confusion
Laennec French
Rale muquex ou
gargouillement
Rale humide ou
crepitation
Rale sibilant sec ou
sifflement
Rale set sonore ou
ronflement
Later English
Coarse rale
Fine rale, crepitation
Sibilant rhonchus
Sonorous rhonchus
American Thoracic Society -1977
“Every physician seems to have his own
classification”
British/American investigations resulted in
new published nomenclature that was
supposed to get everyone communicating
more clearly.
Adventitious sounds:
“continuous” if long (>250 msec)
“discontinuous” if short (< 250 msec)
Continuous Adventitious Sounds
Wheeze
Stridor
Rhonchus
Late inspiratory squeak
Wheeze
Musical, higher pitched; hissing, squeaking,
whistling
Indicates bronchiolar obstruction
Expiratory before inspiratory
Wheezing
Inspiratory and expiratory: worse
disease than expiratory alone.
Stridor
A hiss, whistle, or shriek; very similar to a
wheeze.
Better heard over upper sternum.
Indicates upper airway obstruction
either inside or outside the thorax .
Stridor
The obstruction closest to the beginning
of the airflow movement creates the
most noise
Inside thorax = expiratory stridor
Above thorax = inspiratory stridor
Stridor
Inspiratory stridor (upper airway obstruction above
thorax) should not be confused with wheezing.
Inspiratory wheezing would always be
accompanied by expiratory wheezing.
Rhonchus
Lower pitched, polytonal, usually
expiratory sound
A snoring, gurgling, bubbling sound.
Indicates expiratory collapse or secretions
of/in larger bronchi.
Rhonchus
Inspiratory Squeak
Late inspiratory “squeak” should not be
confused with a wheeze because an
inspiratory-only wheeze should not exist.
Heard in pulmonary fibrosis, allergic
alveolitis, and BOOP
Rhonchi
Squeak
Discontinuous Adventious Sounds
Crackles
Fine
Coarse
Fine Crackles
High pitched, mid-to late inspiratory;
usually over dependent parts of lung; not
changed by cough or position
Like locks of hair rubbed by your ear
Fine Crackles
Coarse Crackles
Lower pitched, longer, louder “popping
sound”; early inspiration and/or
expiration; any lung region; change with
cough
Like Velcro pulled apart
Coarse Crackles
Crackles
Normals may have a few fine crackles over
lower lobes with deep breathing.
Fine crackles: left heart failure,
pulmonary fibrosis, asbestosis,
granulomatous infections
Coarse crackles: bronchopneumonia,
bronchitis, bronchiectasis
Coarse Crackles
Pure pneumonia may have no crackles at
all. Any crackles should be coarse,
reflecting the bronchial component.
Pleural Rub
Loud and creaky as two inflamed pleural
surfaces rub; confused with rhonchi or
coarse crackles; often highly localized
Lower pitch, loudest during inspiration
which helps distinguish it from rhonchi.
Egophony
“Goat sound”: any spoken vowel (usually
“E”) is transmitted through the lung to the
overlying chest wall as a nasal “ay”
The change may be subtle
Most sensitive sign of consolidation;
occasional false (+) with patchy fibrosis
Absent
Present
Egophony
Consolidation Signs
Increased tactile fremitus
Bronchial (tubular) lung sounds
Egophony (most sensitive)
Whispered pectoriloquy and
bronchophony are worse than egophony
and can be skipped.
Consolidation Signs
If a dense infiltrate is clearly present on
imaging, but there are no bronchial lung
sounds and no egophony:
Worry about a closed airway (mucus
plug, tumor).
Pleural Effusion
Dullness to percussion
Elevated dullness boundary by
AP
Decreased lung sounds
Layer of consolidation findings
over effusion (due to atelectasis)
Occasionally, consolidation
findings may be more
generalized over effusion.
END