Respiratory system
Symptoms / Chief complaint
• Cough
• Sputum
• Hemoptysis
• Dyspnea
• Chest pain (chest tightness / discomfort)
• Wheezing
Symptoms / Chief complaint
• Cough
• Sputum
• Hemoptysis
• Dyspnea
• Chest pain (chest tightness / discomfort)
• Wheezing
Cough
• Type
– Dry, Productive , Short, Brassy, Bovine ,Barking , whooping,
Cough syncope, Nocturnal, Drug induced
• Onset & Duration
• Pattern : activities, time of day, weather
• Severity
• Timing and associated features
Causes of cough:
Normal chest X-ray
Abnormal chest
X-ray
Acute cough Viral respiratory tract infection,
(<3 weeks)
Bacterial infection (acute bronchitis),
Inhaled foreign body,
Inhalation of irritant, dusts/fumes
Pneumonia,
Inhaled foreign body,
Acute hypersensitivity
Pneumonitis
Chronic
cough
(>8 weeks)
Lung tumor, TB,
Interstitial lung disease,
Bronchiectasis
GERD, Asthma,
Post viral bronchial hyper reactivity,
Rhinitis/sinusitis, Cigarette smoking
Drugs (ACE inhibitors,
Irritant dusts/fumes)
Macleod’s Clinical examination 13th edition
‘Reg Flag’ symptoms
Macleod’s Clinical examination 13th edition
Sputum
• Sputum is mucus produced from the respiratory tract. The
normal lung produces about 100 ml of clear sputum each day,
which is transported to the oropharynx and swallowed
• Amount
• Color
• Presence of blood (hemoptysis)
• Odor
• Consistency
Color & Consistency:
Type
Appearance
Cause
Serous
Clear, watery,
Frothy, pink
Alveolar cell cancer,
Acute pulmonary oedema
Mucoid
Clear, grey
Chronic bronchitis/COPD
White, viscid
Asthma
Yellow
Acute bronchopulmonary infection
Asthma (eosinophils)
Purulent
Rusty
Green
Longer-standing infection, Pneumonia
Bronchiectasis, Cystic fibrosis, Lung
abscess
Rusty red
Pneumococcal pneumonia
Macleod’s Clinical examination 13th edition
Macleod’s Clinical examination 13th edition
Haemoptysis
• coughing up blood from the respiratory tract
Macleod’s Clinical examination 13th edition
Causes
Malignant
• Lung cancer
• Endobronchial metastases
Benign
• Bronchial carcinoid
Vascular
• Pulmonary infarction
• Vasculitis
• Iatrogenic
• Transthoracic lung biopsy
• Acute left ventricular failure
• Polyangiitis
• Inhaled foreign body
• Mitral valve disease
• Blood dyscrasias
Infection
• Bronchiectasis
• Lung abscess
• Mycetoma
• Cystic fibrosis
• Tuberculosis
• Arteriovenous malformation
• Goodpasture’s syndrome
• Bronchoscopic biopsy
• Bronchoscopic diathermy
• Anticoagulation
• Trauma
• Chest trauma
• Haematological
Dyspnoea
• Dyspnoea (breathlessness) is undue awareness of
breathing and is normal with strenuous physical
exercise.
• Patients use terms such as ‘shortness of
breath’,‘difficulty getting enough air in’, or ‘tiredness
Grades: M R C classification:
– Grade I: Breathless when hurrying on the level or walking up
a slight hill
– Grade II: Breathlessness when walking with people of own
age or on level ground
– Grade III: Walks slower than peers, or stops when walking
on the flat at own pace
– Grade IV: Stops after walking 100 metres, or a few minutes,
on the level
– Grade V: Too breathless to leave the house (Too breathless
to wash or dress )
Macleod’s Clinical examination 13th edition
Modes of onset, duration and progression
Minutes
• Pulmonary thromboembolism
• Pneumothorax, Asthma, Inhaled foreign body
• Acute left ventricular failure
Hours to days
• Pneumonia, Asthma , Exacerbation of COPD, LHF
Weeks to months
• Anaemia, Pleural effusion, Respiratory neuromuscular
disorders
Months to years
• COPD, Pulmonary fibrosis, TB, Muscle weakness
Macleod’s Clinical examination 13th edition
Variability
• Orthopnoea :Breathlessness when lying flat (LVF)
• Platypnoea: Breathlessness on sitting up with relief
on lying down right-to-left shunting
• Trepopnoea : Breathlessness when lying on one side
is due to unilateral lung disease dilated
Cardiomyopathy
• Paroxysmal nocturnal dyspnoea : wakes
the patient from sleep
• Breathlessness improving at weekends or
holidays  occupational asthma.
Causes of Breathlessness
• Cardiorespiratory
–
–
–
–
–
Anaemia
Metabolic acidosis
Obesity
Psychogenic
Neurogenic
• Cardiac
–
–
–
–
–
Left ventricular failure
Mitral valve disease
Cardiomyopathy
Constrictive pericarditis
Pericardial effusion
Macleod’s Clinical examination 13th edition
Respiratory
Airways
• Laryngeal tumour
• Foreign body
• Asthma
• COPD
• Bronchiectasis
• Lung cancer
• Bronchiolitis
• Cystic fibrosis
Pulmonary circulation
• Pulmonary
thromboembolism
• Pulmonary vasculitis
• Primary pulmonary
hypertension
Parenchyma
• Pulmonary fibrosis
• Alveolitis
• Sarcoidosis
• Tuberculosis
• Pneumonia
• Diffuse infections, e.g.
Pneumocystis jiroveci
pneumonia
• Tumour (metastatic,
lymphangitis)
Pleural
• Pneumothorax
• Effusion
• Diffuse pleural fibrosis
Chest wall
• Kyphoscoliosis
• Ankylosing spondylitis
Neuromuscular
• Myasthenia gravis
• Neuropathies
• Muscular dystrophies
• Guillain–Barré syndrome
Macleod’s Clinical examination 13th edition
Chest pain
• Chest pain can originate from the parietal pleura, the
chest wall and mediastinal structures .
• Pleural pain
• Chest wall pain
• Mediastinal pain
• Retrosternal pain
– Upper
– Lower
Causes of Chest pain
Non- Central
Pleural
• Infection: pneumonia,
bronchiectasis, tuberculosis
• Malignancy: lung cancer,
mesothelioma, metastatic
• Pneumothorax
• Pulmonary infarction
• Connective tissue disease:
rheumatoid arthritis, SLE
Chest wall
• Malignancy: lung cancer, mesothelioma,
bony metastases
• Persistent cough/breathlessness
• Muscle sprains/tears
• Bornholm’s disease (Coxsackie B
infection)
• Tietze’s syndrome (costochondritis)
• Rib fracture, • Intercostal nerve
compression, • Thoracic shingles (herpes
zoster)
Central
Central
Tracheal
• Infection
• Irritant dusts
Cardiac
• Massive pulmonary
thromboembolism
• Acute MI/
ischaemia
Oesophageal
• Oesophagitis
• Rupture
Great vessels
• Aortic
dissection
Mediastinal
• Lung cancer
• Thymoma
• Lymphadenopathy
• Metastases
• Mediastinitis
• Past History
– Similar illness
– TB, Asthma, IHD, DM
– Childhood illness- measles, inflenza, whooping
cough
– Recent travel
• Family history
– Similar illness
– DM,TB, HT, IHD,
– Parents marriage: consanguineous
– Asthma, Eczema
• Personal history
–
–
–
–
–
Appetite
Veg/non-veg
Bowel & bladder
Alcohol- amount & duration
Smoking-No., duration (smoking index)
• Menstrual history
– Menarche, LMP
– Regular, amount
– Associated pain
• Treatment History
General examination
•
•
•
•
•
•
•
•
•
•
Built
Nourishment
Dyspnoea
Cyanosis
Anemias
Jaundice
Clubbing
Lymphadenopathy
Eye
Pedal edema
Cyanosis
Grades and Examination of Clubbing
Causes of clubbing
A. Bronchopulmonary diseases
• Bronchiectasis
• Lung abscess
• Bronchogenic carcinoma
• Emphysema
B. Cardiac diseases
• Congenital cyanotic heart disease
• Subacute bacterial endocarditis
Lymphatic and Veins
• Lymph node:
– Parietal pleura  axillary lymph node
– Whole right lung& left lower lobe  right
supraclavicular lymph node
– Left upper lobe  left supraclavicular lymph
node
• Veins:
– Superior vena caval syndrome
Examination of the neck
• Scalene Lymph Node
– Large and fixed : Primary lung malignancy
– Hard, craggy, matted, with/out sinus
formation: calicified TB lymphadenopathy
• Other significant nodes:
– Supraclavicular
– Cervical
– Axillary
External manifestations
•
•
•
•
•
•
•
Asterixis
Halitosis
Gynaecomastia
Horner’s syndrome
Small muscle wasting
External markers of TB
External markers of cor pulmonale
Examination
What is the most important start to any exam ??
Introduce yourself to the patient
and let them know what you are
about to do …
Take consent before examination!
Systemic Examination of
Respiratory system
Inspection/Observation
• Upper Respiratory Tract
– Oral
– Nosecavity
– Pharynx
- Tonsils
-Throat
• Lower Respiratory Tract
– Supraclavicular area
– Infraclavicular area
– Mammary region
– Axillary region
– Infra axillary region
- Suparscapular region
-Interscapular region
- Infrascapular region
• Shape
• Bilateral movement
• Subcoastal angle
• Dyspnea
• Accessory muscles
• Trachea position
• Apex beat
• Shoulder drooping
• Spine position
• Visible scars/ dilated veins/ sinuses
• Position of Trachea:
– Trail’s sign
• Position of the apex beat
Chest Deformities
• Flat chest
• Barrel chest
• Pectus Carinatum
• Pectus excavatum: It’s the exaggeration of
the normal hollowness over the lower end
of the sternem.
• Harrison’s sulcus:
• Rickety rosary:
• Scorbutic rosary:
Spine Abmormalites
• Kyphosis: Causes the patient to be bent forward.
• Ankylosing spondylitis: Diminished volume of lung &
capacity of the chest
• Scoliosis: spine is curved to either the left
or right.
Movement of the chest
• Rate
• Rhythm
• Equality
• Type of breathing
Rate
•
•
•
•
Normal: 14-18 breaths/min
Type of breathing
Pulse : Respiratory rate (4:1)
Tachyponea:
– Nervousness, fever, hypoxia, exertion
– APE, Pneumonia, Pul. Emobolism, ARDS, Metabolic
acidosis
• Bradypnoea:
– Alkalosis, Hypothyroidism, raised ICT
• Hyperpnoea:
– Acidosis, brainstem lesion, Hysteria
Rhythm
Inspiration: by the contraction Of the external intercostal muscles and the diaphragm
Expiration: Depends upon the elastic recoil of the lungs
Abnormal breathing patterns
• Cheyne-Stokes respirations
– Hyperpnoea followed by apnoea
– periods of respirations during which the tidal volume
starts shallow and gets progressively deeper, and
then gets progressively shallower.
– Causes: strokes, traumatic brain injuries, brain
tumors, CO poisoning, and metabolic
encephalopathy, normal side-effect of morphine
administration.
• Kussmaul's Breathing:
– Labored hyperventilation characterized by a deep
and rapid respiratory pattern.
– Causes: late stages of a severe metabolic
acidosis (DKA).
• Apneustic Breathing:
– prolonged inspiratory phases with each
breathe, followed by a prolonged expiratory
phase
– causes: lesion to the upper part of the pons
• Ataxic Breathing:
– A completely irregular breathing pattern with irregular
pauses and unpredictable periods of apnea.
– Cause: lesion to the medulla oblongata secondary to
trauma or stroke.
– very poor prognosis.
• Biot's Breathing
• Apnoea between several shallow or few deep inspirations
• It is very similar to Cheyen-Stokes except the spontaneous tidal
volume is equal throughout the period of respiration.
• Causes: Lesions to the medulla oblongata by CVA or trauma, or
pressure on the medulla due to uncal or tenorial herniation,
prolonged opioid abuse.
Palpation
•
•
•
•
•
Position of the trachea
Apex position
Rib crowding
Bony tenderness
Lymphnode
– Axillary
– Cervical
– Supraclavicular
• Measurement of chest expansion
Assessment of chest expansion
• Anterior Thoracic Movement:
• Posterior Thoracic Movement:
Tactile Fremitus
Location:
Assessing Fremitus:
Percussion
Percussion Areas:
Anterior & Lateral
Posterior
Methods of Percussion
Auscultation
Vesicular
Inspiratory sounds
lasts longer than
expiratory sounds
Soft
Over most of
lungs
Bronchovesicul
ar
Inspiration and
expiration sounds
are equal.
Intermediate
Angle of
louis/between
scapulae.
Bronchial
Expiratory sounds
last longer than
expiratory ones.
Loud
Over
manubrium
sternum.
Tracheal
Inspiratory and
expiratory are about
equal
Very loud
Over trachea in
neck.
Listen with intent for

Breath sounds to the bases

Equal breath sounds

Inspiration

Expiration

Abnormal breath sounds



Absent or diminished breath sounds
Displaced bronchial breath sounds
Adventitious breath sounds
Crackles

Most common cause air passing through fluid (other?)

Fine = Smaller airways

Coarse = Larger airways

Predominantly heard on inspiration

Can be equal both lungs

Can be isolated to one area
Wheezes

Produced by air forcing its way through narrowed
airways (bronchoconstricted)

High pitched musical sounds heard on expiration

Can be heard on inspiration

Smooth Muscles Irritation = Bronchoconstriction

Stridor

High pitched continuous crowing sound that is
heard over the trachea and larynx

Stethoscope not normally needed

Best heard over neck

Partial airway obstruction from:

foreign objects, swelling
Pleural Rub


Constant grating sound that is heard on inspiration
and expiration
Caused from parietal and visceral pleura rubbing
together

Pleura inflamed (loss of serous fluid)

Usually localized
Proper Auscultation Procedure



Attempt to place patient in sitting position
Attempt to minimize as much outside noise as
possible
Encourage patient not to make any moaning and
groaning noises
Where should I listen?
Anterior Chest
Posterior Chest