Main complaints of patients with diseases of respiratory organs.

Main complaints of patients with diseases of respiratory organs. Static and dynamic inspection of a chest. Palpation of a chest.

Percussion of lungs. The method and technique of comparative percussion of lungs.

The method and technique of  topographic percussion of lungs.

 

Inquiry of patients with respiratory pathology

Complaints of patients with respiratory pathology

The main complaints typical for the respiratory system are dyspnoea, cough, bloody expectorations, and pain in the chest. Fever, asthenia, indisposition and loss of appetite are not infrequent.

Dyspnoea in its manifestation can be subjective, objective, or subjective and objective simultaneously. By subjective dyspnoea is understood the subjective feeling of difficult or laboured breathing. Objective dyspnoea is determined by objective examination and is characterized by changes in the respiration rate, depth, or rhythm, and also the duration of the inspiration or expiration. Diseases of the respiratory system are often accompanied by mixed (i.e. subjective and objective) dyspnoea. It is often associated with rapid breathing (tachypnoea). These symptoms occur in pneumonia, bronchogenic cancer, and in tuberculosis. Cases with purely subjective dyspnoea (in hysteria, thoracic radiculitis) or purely objective dyspnoea (in pulmonary emphysema or pleural obliteration) occur less frequently. Dyspnoea is possible with both normal and slow rate of breathing (bradypnoea). Three types of dyspnoea are differentiated by the prevalent breathing phase: inspiratory dyspnoea, expiratory dyspnoea and mixed dyspnoea when both expiration and inspiration become difficult.

Dyspnoea may be physiological (caused by heavy exercise) and pathological (associated with pathology of the respiratory organs, diseases of the cardiovascular and haemopoietic systems, and poisoning).

Dyspnoea associated with respiratory pathology may be of various aetiology. It can be caused by obstruction of the respiratory ducts, contraction of the respiratory surface of the lungs due to their compression by liquid or air accumulated in the pleural cavity, decreased pneumatization of the lung in pneumonia, atelectasis, infarction or decreased elasticity of the lungs. These conditions are associated with decreased total (vital) lung capacity and ventilation, which causes increased carbon dioxide content of blood, and acidosis of tissues due to accumulation in them of incompletely oxidized metabolites (lactic acid, etc.). The so-called alveolar-capillary block is also possible in some cases. This is associated with exudative and proliferative inflammation of the interstitial tissue in interstitial pneumonia or lung oedema.

A mechanical obstruction in the upper respiratory ducts (larynx, trachea) complicates and slows down passage of the air into the alveoli and causes inspiratory dyspnoea. When the trachea and a large bronchus are sharply contracted, both inspiration and expiration become difficult and noisy (stridulous respiration) occurs. Narrowed lumen in the fine bronchi and bronchioles due to inflammatory oedema and swelling of their mucosa, or else in spasms in the smooth muscles (bronchial asthma), interferes with normal air passage from the alveoli and the expiration becomes difficult. Expiratory dyspnoea thus develops. The patient has to assume a forced, sometimes sitting posture (orthopnoea) to remove the discomfort. Heavy dyspnoea, often followed by asphyxia, is called suffocation. It occurs also in acute oedema of the lungs, bronchiolitis in children, and in fibrinous bronchitis. Asphyxia arising as a sudden attack is asthma. Bronchial asthma, in which an attack of dyspnoea occurs as a result of spasms of smaller bronchi and is accompanied by difficult, lengthy and noisy expiration, is differentiated from cardiac asthma which is secondary to left heart failure and is often accompanied by lung oedema with very difficult expiration.

 

 

Cough is a complicated reflex act which is actually a defence reaction aimed at clearing the larynx, trachea, or bronchi from mucus or foreign material. An inflamed bronchial mucosa produces a secretion which acts on the sensitive reflexogenic zones in the respiratory mucosa to stimulate the nerve endings and to activate the coughing reflex.

 

 

Cough may be dry, without sputum, and moist  which various amounts of sputum of different quality are expected. Some diseases are attended only by dry cough, e.g. laryngitis, dry pleurisy or compression of the main bronchi by the bifurcation lymph nodes (tuberculosis, lymphogranulomatosis, cancer metastases, etc.). Bronchitis, pulmonary tuberculosis, pneumosclerosis, abscess, or bronchogenic cancer of the lungs can be first attended by dry cough, which will then turn into moist one with expectoration of the sputum.

 

 

If a patient complains of cough with sputum, the physician should try to determine the amount of sputum expectorated during one fit and during the entire day; it is also important to know the time of the day during which the sputum is expectorated and the position of the body at which cough is provoked; the colour, odour, and other properties of sputum are also important. Morning cough is characteristic of patients with chronic bronchitis, bronchiectasis, lung abscess, and cavernous tuberculosis of the lungs. The sputum accumulates during the night sleep in the lungs and the bronchi, but as the patient gets up, the sputum moves to the neighbouring parts of the bronchi to stimulate the reflexogenic zones of the bronchial mucosa. This causes cough and expectoration of the sputum. The amount of the sputum expectorated during the morning may amount to two thirds of the entire daily expectoration. Depending on the gravity of the inflam­matory process in patients with mentioned diseases, the daily amount of the expectorated sputum may vary from 10—15 ml to as much as 2 litres. In unilateral bronchiectasis, sputum may be better expectorated in a definite posture, for example, on the right side with bronchiectasis in the left lung, and vice versa. If bronchiectasis is found in the anterior region of the lungs, expectoration is easier in the supine position, and if in the posterior parts, in the prone position.

Many patients, particularly smokers, assume that coughing is a normal life experience. It may be difficult to quantify the problem, particularly if the cough is dry. If productive, work out the amount, an eggcupful a day perhaps? Is the sputum mucoid or purulent, is the sputum white or grey, or more yellow-green in colour?

Patients with pneumonia and bronchitis may complain of cough attacks during the entire day, but attacks may intensify by night (“evening” cough). “Night” cough is characteristic of tuberculosis, lymphogranulomatosis, or malignant newgrowths. Enlarged mediastinal lymph nodes in these diseases stimulate the reflexogenic zone of the bifurcation, especially during night when the tone of the vagus nerve increases, to produce the coughing reflex.

Cough is differentiated by its length. It may be permanent and periodic. Permanent cough is rarer and occurs in laryngitis, bronchitis, bronchogenic cancer of the lungs or metastases into the mediastinal lymph nodes, and in certain forms of pulmonary tuberculosis. Periodic cough occurs more frequently.

 Cough is also classified by its loudness and timbre. Loud barking cough is characteristic of whooping cough, compressed trachea (due to retrosternal goitre or tumour), affection of the larynx and swelling of the false vocal cords, and in hysteria; soft cough or tussiculation (hacking cough) is characteristic of the first stage of acute lobar pneumonia, dry pleurisy and the early stage of pulmonary tuberculosis. Inflammation of the vocal cords is attended by strong cough while ulceration of the cords is characterized by voiceless cough.

Haemoptysis is expectoration of blood with sputum during cough. The physician must determine the origin of haemoptysis and the amount and character of blood expectorated with sputum. Haemoptysis can develop in diseases of the lungs and air ways (bronchi, trachea or larynx), as well as in diseases of the cardiovascular system. Pulmonary tuberculosis and cancer, virus pneumonia, bronchiectasis, abscess and gangrene of the lung, actinomycosis, tracheitis and laryngitis associated with virus influenza are often attended by haemoptysis. This symptom is also characteristic of some heart defects, thrombosis or embolism of the pulmonary arteries and subsequent pulmonary infarction.

 

If the patient has coughed up blood, find out whether this represents fine blood-streaking of the sputum or a more conspicuous amount. Is it a recent event, or has it happened periodically over several years? Did it follow a particularly violent bout of coughing?

The amount of blood expectorated with sputum is mostly scant. Blood appears in the form of thin streaks, or it may give diffuse colouration to the sputum, which can be jelly-like or foamy. Cavernous tuberculosis, bronchiectases, degrading tumour and pulmonary infarction may be attended by lung haemorrhage, which is usually accompanied with strong cough.

Blood expectorated with sputum can be fresh and scarlet, or altered. Scarlet blood in the sputum is characteristic of pulmonary tuberculosis, bronchogenic cancer, bronchiectasis, and actinomycosis of the lungs. Blood expectorated with sputum in acute lobar pneumonia (second stage) has the colour of rust (rusty sputum) due to decomposition of the red blood cells and formation of the pigment haemosiderin. Blood in the sputum is fresh and scarlet during the first 2-3 days in lung infarction while in subsequent 7-10 days it becomes altered.

Pain in the chest is classified by its location, origin, character, intensity, duration, and irradiation, by its connection with the respiratory movements, cough, and the posture. Pain may arise during the development of a pathological condition in the thoracic wall, the pleura, heart, and the aorta, and in diseases of the abdominal organs (by irradiation). Special clinical signs are characteristic of pain of any particular origin, and in this respect pain may have diagnostic value.

Pain in the chest in diseases of the respiratory organs depends on irrita­tion of the pleura, especially of the costal and diaphragmal parts where sensitive nerve endings are found. (They are absent in the pulmonary tissue.) Pleura may be injured during its inflammation (dry pleurisy), in subpleural pneumonia (acute lobar pneumonia, lung abscess, pulmonary tuberculosis), in lung infarction, tumour metastasis into the pleura or development in it of the primary tumour, in injury (spontaneous pneumothorax, wound, rib fracture), in subdiaphragmal abscess, and in acute pancreatitis.

Localization of pain depends on the pathological focus. Pain in the left or right inferior part of the chest (pain in the side) is characteristic of dry pleurisy. Inflammation of the diaphragmal pleura may be manifested by pain in the abdomen to simulate acute cholecystitis, pancreatitis, or appendicitis.

Pleural pain is often piercing, while in diaphragmal pleurisy and spontaneous pneumothorax it is acute and intense. Pain is intensified in deep breathing, coughing, or when the patient lies on the healthy side. The respiration movements in this position become more intense in the affected side of the chest to strengthen friction of the inflamed pleura (rough from deposited fibrin). Pain lessens when the patient lies on the affected side. Pleural pain is also lessened when the chest is compressed to decrease the respiratory excursions.

Before concentrating on individual systems ask some general questions about the patient’s health. Is the patient sleeping well? If not, is there a problem getting to sleep or a tendency to wake in the middle of the night or in the early hours of the morning? Has there been weight loss, fevers, rashes or night sweats? This leads in to the systems’ enquiry. The questions surrounding the presenting complaint will often have completed the systematic enquiry for that organ and there is no need to repeat questions already asked but simply to indicate ‘see above’. Develop a routine that helps to avoid missing out a particular system.

 

 

Data of anamnesis

When questioning the patient the physician should determine the time the disease began. Acute onset is characteristic of acute pneumonia, especially acute lobar pneumonia. Pleurisy begins more gradually. A non-manifest onset and a prolonged course are characteristic of pulmonary tuberculosis and cancer. The onset of many diseases may be provoked by chills (bronchitis, pleurisy, pneumonia).

Determining epidemiological conditions is very important for establishing the cause of the disease. Thus influenzal pneumonia often occurs during epidemic outbreaks of influenza. Establishing contacts with tuberculosis patients is also very important. Specific features of the course of the disease and the therapy given (and its efficacy) should then be established.

When collecting the life anamnesis, the physician should pay attention to conditions under which the patient lives and works. Damp premises with inadequate ventilation or work in the open (builders, truck drivers, agricultural workers, etc.) can become the cause of acute inflammation of the lungs with more frequent conversion into chronic diseases. Some dusts are harmful and cause bronchial asthma. Coal dust causes a chronic disease of the lungs called anthracosis. Regular exposure to silica dust (cements, pottery, etc.) causes silicosis, the occupational fibrosis of the lungs.

The patient should give a detailed report of his past diseases of the lungs or pleura, which helps the physician establish connections between the present disease and diseases of the past history.

 

Data of objective examination

By inspection the examiner can reveal diffuse cyanosis in the case of respiratory failure:

 

 

 

 

 

Pay attention to colour of visible mucosa (cyanosis):

 

Inspection of the neck shoves svelling of neck veins in elevation of intrathoracic pressure:

You can see swelling of neck veins in superior vena cava obstruction and dilation of superficial veins on the chest

 

 

Patients with chronic hypoxia develop clubbing fingers

Herpes labialis et nasalis develop in heavy pneumonia

Examination of the chest is done according to a definite plan. Inspection of a chest is divided on static and dynamic one.

 

Static inspection of the chest

The general configuration of the chest should first beestimated (position of the clavicles, supra- and subclavicular fossae, shoulder blades)$ the next step is to define the type, rrhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder girgle, and involvement of the accesory respiratory muscles in the breathing act. The patient should be better examined in the upright (standing or sitting) position with the chest being naked. Illumination of the body should be uniform.

Body symmetry is always an important notation during the inspection of the chest. Asymmetry in the chest may indicate serious underlying problems, such as pulmonary dysfunction. However, asymmetry is most often a sign of scoliosis, lateral curvature of the spine. Asymmetry requires further medical investigation.

The shape of the chest may be normal or pathological. A normal chest is characteristic of healthy persons with regular body built. Its right and left sides are symmetrical, the clavicles and the shoulder blades should be at one level and the supraclavicular fossae equally pronounced on both sides. Sinse all people with normal constitution are conventionally divided into three types, the chest has different shape in accordance with its constitutional type.

 

Pathological shape of the chest may be the result of congential bone defects and of vatious cjronic diseases (emphysema of the lungs, rickets, tuberculosis).

 

Normal form of the chest

. 1. Normosthenic (conical) chest in subjects with normosthenic constitution resembles a truncated cone whose bottom is formed by well-developed muscles of the shoulder girdle and is directed upward. The anteroposterior (sterno vertebral) diameter of the chest is smaller than the lateral (transverse) one, and the supraclavicular fossae are slightly pronounced. There is a distinct angle between the sternum and the manubrium (angulus Ludowici); the epigastric angle nears 90°. The ribs are moderately inclined as viewed from the side; the shoulder blades closely fit to the chest and are at the same level; the chest is about the same height as the abdominal part of the trunk.

2. Hypersthenic chest in persons with hypersthenic constitution has the shape of a cylinder. The anteroposterior diameter is about the same as the transverse one; the supraclavicular fossae are absent (level with the chest). The manubriosternal angle is indistinct; the epigastric angle exceeds 90°;

the ribs in the lateral parts of the chest are nearly horizontal, the intercostal space is narrow, the shoulder blades closely fit to the chest, the thoradc part of the trunk is smaller than the abdominal one.

3. Asthenic chest in persons with asthenic constitution is elongated, narrow (both the anteroposterior and transverse diameters are smaller thaormal); the chest is flat. The supra- and subclavicular fossae are distinctly pronounced. There is no angle between the sternum and the manubrium: the sternal bone and the manubrium make a straight “plate”. The epigastric angle is less than 90°. The ribs are more vertical at the sides, the tenth ribs are not attached to the costal arch (costa decima fluctuens); the intercostal spaces are wide, the shoulder blades are winged (separated from the chest), the muscles of the shoulder girdle are underdeveloped, the shoulders are sloping, the chest is longer than the abdominal part of the trunk.

Pathological chest

1. Emphysematous (barrel-like) chest resembles a hypersthenic chest in its shape, but differs from it by a barrel-like configuration, prominence of the chest wall, especially in the posterolateral regions, the intercostal spaces are enlarged. This type of chest is found in chronic emphysema of the lungs. Active participation of accessory respiratory muscles in the respiratory act (especially m. sternocleidomastoideus and m. trapezius), depression of the intercostal space, elevation of the entire chest during inspiration and relaxation of the respiratory muscles and lowering of the chest to the initial position during expiration become evident during examination of emphysema patients.

 

General appearance of a patient with pulmonary emphysema

 

2. Paralytic chest resembles the asthenic chest. It is found in emaciated patients, in general asthenia and constitutional underdevelopment; it often occurs in grave chronic diseases, more commonly in pulmonary tuberculosis and pneumosclerosis. During examination of patients with paralytic chest, marked atrophy of the chest muscles and asymmetry of the clavicles and dissimilar depression of the supraclavicular fossae can be observed along with typical signs of aslhenic chest. The shoulder blades are not at one level either, and their movements during breathing are asynchronous.

 

 

Paralytic chest

 

3. Rachitic chest (keeled or pigeon chest). It is characterized by a markedly greater anteroposterior diameter (compared with the transverse diameter) due to the prominence of the sternum (which resembles the keel of a boat.) The anterolateral surfaces of the chest are as if pressed on both sides and therefore the ribs meet at an acute angle at the sternal bone, while the costal cartilages thicken like beads at points of their transition to bones (rachitic beads). As a rule, these beads can be palpated after rickets only in children and youths.

1.     Funnel chest has a funnel-shaped depression in the lower part of the sternum. This deformity can be regarded as a result of abnormal development of the sternum or prolonged compressing effect. In older times this chest would be found in shoemaker adolescents.

5. Foveated chest is almost the same as the funnel chest except that the depression is found mostly in the upper and the middle parts of the anterior surface of the chest. This abnormality occurs in syringomyelia, a rare disease of the spinal cord.

The chest may be abnormal in subjects with various deformities of the spine which arise as a result of injuries, tuberculosis of the spine, rheumatoid arthritis (Bekhterev’s disease), etc. Four types of spine deformities are distinguished: lateral curvature of the spine, called scoliosis; excessive forward and backward curvature of the spine (gibbus and kyphosis, respectively); forward curvature of the spine, generally in the lumbar region (lordosis); combination of the lateral and forward curvature of the spine (kyphoscoliosis).

 

 

Different types of chest deformities

 

The shape of the chest can readily change due to enlargement or diminution of one half of the chest (asymmetry of the chest). These changes can be transient or permanent.

The enlargement of the volume of one half of the chest can be due to escape of considerable amounts of fluid as the result of accumulation of fluid in the pleural cavity, or due to penetration of air inside the chest in injuries (pneumothorax). Levelling or protrusion of the intercostal spaces, asymmetry of the clavicles and the shoulder blades and also unilateral thoracic lagging can be observed during examination of the enlarged part of the chest.

One part of the chest may diminish due to pleural adhesion or complete closure of the pleural slit after resorption of effusion (after prolonged presence of the fluid in the pleural cavity); contraction of a considerable portion of the lung due to growth of connective tissue (pneumosclerosis) after acute or chronic inflammatory processes, such as acute lobar pneumonia (with subsequent carnification of the lung), lung infarction, pulmonary abscess, tuberculosis, etc.;resection of a pan or the entire lung; atelectasis (collapse of the lung or its portion) that may occur due to closure of the lumen in a large bronchus by a foreign body or a tumour growing into the lumen of the bronchus and causing its obturation. The closure of the air passage into the lung with subsequent resorption of air from the alveoli and a decrease in the volume of the lung diminish the corresponding half of the chest. The chest thus becomes asymmetrical, the shoulder of the affected side lowers, the clavicle and the scapula lower as well, and their movements during deep respiration become slower ttnd limited; the supra- and subclavicular fossae become more depressed, the intercostal spaces decrease in size or become invisible. The marked depression of the supraclavicular fossa on one side often depends on the diminution of the apex of a fibrosis-affected lung.

 

Dynamic inspection. Inspection of the lungs involves primarily observation of respiratory movements, which are discussed. Respirations are evaluated for (1) rate (number per minute), (2) rhythm (regular, irregular, or periodic), (3) depth (deep or shallow), and (4) quality (effortless, automatic, difficult, or labored). The doctor also notes the character of breath sounds based on inspection without the aid of auscultation, such as noisy, grunting, snoring, or heavy.

Movement of the chest wall is noted. It should be symmetric bilaterally and coordinated with breathing. During inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases. During expiration the chest falls and decreases in size, the diaphragm rises, and the costal angle narrows.

Any asymmetry of movement is an important pathologic sign and is reported. Decreased movement on one side of the chest may indicate pneumonia, pneumothorax, atelectasis, or an obstructive foreign body. Marked retraction of muscles either between the ribs (intercostal), above the sternum (suprasternal), or above the clavicles (supraclavicular) is always noted, because it is a sign of respiratory difficulty.

 

Normal respiratory rate is 16-20 per min. The respiratory rate is always evaluated in relation to general physical status. For example, tachypnea is expected with fever, because for every degree Fahrenheit elevation in temperature, the respiratory rate increases 4 breaths per minute. The usual ratio of breaths to heartbeats is 1:4.

Respiratory movements of the chest should be examined during inspection of the patient. In physiological conditions they are performed by the contraction of the main respiratory muscles: intercostal muscles, muscles of the diaphragm, and partly the abdominal wall muscles. The so-called accessory respiratory muscles (mm. sternocleidomastoideus, trapezius, pectoralis major et minor, etc.) are actively involved in the respiratory movements in pathological conditions associated with difficult breathing.

The type, frequency, depth and rhythm of respiration can be determined by carefully observing the chest and the abdomen. Respiration can be costal (thoracic), abdominal, or mixed type.

Thoracic (costal) respiration. Respiratory movements are carried out mainly by the contraction of the intercostal muscles. The chest markedly broadens and slightly rises during inspiration, while during expiration it narrows and slightly lowers. This type of breathing is known as costal and is mostly characteristic of women.

Abdominal respiration. Breathing is mainly accomplished by the diaphragmatic muscles; during the inspiration phase the diaphragm contracts and lowers to increase rarefaction in the chest and to suck in air into the lungs. The intra-abdominal pressure increases accordingly to displace anteriorly the abdominal wall. During expiration the muscles are relaxed, the diaphragm rises, and the abdominal wall returns to the initial position. This type of respiration is also called diaphragmatic and is mostly characteristic of men.

Mixed respiration.    The respiratory movements are carried out simultaneously by the diaphragv and the intercostals muscles.

 

Respiration rate may be determined by counting the movements of the chest or the abdominal wall, while the patient is being unware of the procedure (during examination of his pulse, for example). Iorm the respiration rate is within 16-20 breathing movements a min. It is increased in dyspnea and rises in the case of inhibition of respiratory center.

Causes of alteration of the respiratory rate:

1)     narrowing of the lumen of small bronchi due to spasms or diffuse inflammation of their mucosa (bronchiolitis occurring mostly in children), which interfere with normal passage of air into the lungs;

2)     decreased respiratory surface of the lungs due to their inflammation and tuberculosis, in collapse or atelectasis of the lung due to its compression (pleuricy with rffusion, hydrothorax,  pneumothorax, mediastinal tumor), in obstruction or compression of the main bronchus by a tumor etc;

3)     insufficient depth of breathing.

 

Pathological deceleration of respiration occurs in functional inhibition of the respiratory centre and its decreased excitability. It van be due to increased intracranial pressure in patients with cerebral tumor, meningitis, cerebral haemorrhage, or oedema of the brain, and also due to the toxic effect on the respiratory centre when toxic substahces are accumulated in the blood, e.g. in uraemia, hepatic or diabetic coma, and in certain acute infectious diseases.

Respiration depth. The depth of breathing is, determined by the volume of the inhaled and exhaled air at rest. This volume varies in an adult from 300 to 900 ml (500 ml on the average). Depending on depth, breathing can be either deep or superficial. Superficial (shallow) breathing often occurs in pathologically accelerated respiration when the length of the inspiration and the expiration phases becomes short. Deep breathing is, on the contrary, associated in most cases with pathological deceleration of the respiration rate. Deep and slow «respiration, with marked respiratory movements, is sometimes attended by noisy sounds. This is Kussmaul’s respiration. occurring in deep coma. In some pathological conditions, however, rare respiration can be shallow, while accelerated breathing deep. Rare superficial respiration can occur in sharp inhibition of the respiratory centre, pronounced lung emphysema, and sharp narrowing of the vocal slit or the trachea. Respiration becomes accelerated and deep in high fever and marked anaemia.

Respiration rhythm. Respiration of a healthy person is rhythmic, of uniform depth and equal length of the inspiration and expiration phases. Rhythm of the respiratory centre can be inhibited, in some types of oedema. Derangement of the respiratory function can (pause oedema in which a series of respiratory movements alternates with a pronounced (readily detectable) elongation of the respiratory pause (lasting from a few seconds to a minute) or to a temporary arrest of respiration (apnoea). This respiration is known as periodic.

Biot’s respiration is characterized by rhythmic but deep respiration movements which alternate (at approximately regular intervals) with 1ong respiratory pauses (from few seconds to half a minute). Biot’s respiration occurs in meningitis patients and in agony with disorders of cerebral circulation.

Cheyne-Stokes’ respiration is characterized by periods (from seconds to a minute) of cessation of respiration, followed by noiseless shallow respiration, which quickly deepens, becomes noisy to attain hj maximum at the 5-7th inhalation, and then gradually slows down to end with a new short respiratory pause. During such pauses, the patient often loses his sense of orientation in the surroundings or even faints, to recover from the unconscious condition after respiratory movements are restored. This respiratory disorder occurs in diseases causing acute or chronic insufficiency of cerebral circulation and brain hypoxia, and also in heavy poisoning. More frequently this condition develops during sleep and is more characteristic of aged persons with marked atherosclerosis of the cerebral arteries.

Undulant (wave-like) Grocco’s respiration somewhat resembles Cheyne-Stoke’s respiration exept that a weak shallow respiration occurs instead of the respiratory pause with subsequent deepening of the respiratory movement, followed by slowing down. This type of arrhythmic dyspnoea  can probably be regarded as the early stages of the same pathological processes which are responsible for resembles Cheyne-Stoke’s respiration.

 

 

 

Pathological respiration

Pathological changes of rhythm and depth of respiration are as follows:

 

Palpation as a method of examination

Palpation involves the use of the doctor’s hands to feel texture, size, shape, consistency, and location of certain parts of the client’s body and also to identify areas the client reports as being tender or painful. This technique requires the doctor to move into the client’s personal space. It is important that the touch is gentle, hands are warm, and nails are short to prevent discomfort or injury to the client. Touch has cultural significance and symbolism. Each culture has its own understanding about the uses and meanings of touch. As a result, it is of utmost importance that doctors tell clients the purpose of their touch (e.g., “I’m feeling for lymph nodes now”) and manner and location of touch (e.g., “I’m going to press deeply on your abdomen to feel the organs”). Gloves are worn when palpating mucous membranes or any other area where contact with body fluids is possible.

The palmar surfaces of fingers and finger pads are more sensitive than the fingertips; thus they are better for determining position, texture, size, consistency, masses, fluid, and crepitus. The ulnar surface of the hand extending to the fifth finger is the most sensitive to vibration, whereas the dorsal surface of the hand is better for assessing temperature.

Palpation using the palmar surfaces of the fingers may be light or deep and is controlled by the amount of pressure applied. For example, when examining the abdomen, light palpation is accomplished by pressing to a depth of approximately 1 cm and is used to assess skin, pulsations, and tenderness. Deep palpation, accomplished by using one or both hands to press in up to 4 cm, is used to determine organ size and contour. Light palpation should always precede deep palpation because palpation may cause tenderness or disrupt fluid, which would interfere with collecting data by light palpation. A bimanual technique of palpation uses both hands, one anterior and one posterior, to entrap an organ or mass between the fingertips to assess size and shape. This technique is used to assess the kidneys and uterus.

 

The sequence and technique  of palpation of a chest

VIDEO_1

 

Palpation of the chest in user for determination of following:

To locate the pain  in the chest and its irradiation – carefully press with your fingers along each intercostal space.

    Resistance or elasticity  of the chest – is determined by exerting preassure of the examining hands from the front to the sides and on the back and the , sternum and also by palpation of intercostal spaces.

The strengs of voice conduction  to the chest surface (vocal fremitus) – The palms of the hands are placed  on the symmetrical parts  of the chest and the patient is asked to utter loudly words with the letter “r” in them.

Palpation is used as an additional means of examination to verify findings of inspection (the shape of the chest, its dimensions, respiratory movements(, for determining local or profuse tenderness of the chest, its elasticity (resilience), vocal fremitus, pleural friction and sounds of fluid in the pleural cavity.

Palpation should be done by placing the palms on the symmetrical (left and right) parts of the chest. This examination helps follow the respiratory excursions and deviation of the chest movements from their normal course. During respiration the hands will move with the chest wall. The doctor evaluates the amount and speed of respiratory excursion, noting any asymmetry of movement. Normally the amplitude of movements are equal on  both chest parts..

Evaluation of respiratory excursion

The epigastric angle as determined by palpation as well. The thumbs should be pressed tightly against the costal arch, their tips resting against the xiphoid process (ensiform cartilage).

Crepitation is felt as a coarse, cracking sensation as the hand presses over the affected area. It is the result of the escape of air from the lungs into the subcutaneous tissues from an injury or surgical intervention. Both pleural friction rubs and crepitation can usually be heard as well as felt.

Palpation is used to locate pain in the chest and its irradiation. For example, in rib fracture, pain is located over a limited site, namely at the point of the fracture. Displacement (careful!) of bone fractures will be attended in this case by a specific sound (crunch). Inflammation of the intercostal nerves and muscles also causes pain, but it can be felt during palpation over the entire intercostal space. Such pain is called superficial. It is intensified during deep breathing, when the patient bends to the affected side, or lies on this side.

Resilience or elasticity of the chest is determined by exerting pressure of the examining hands from the front to the sides of the chest or on the back  at the sternum, and also by palpation of the intercostal spaces. The chest of a  healthy person is elastic, plaint and yields under the pressure. In the presence of pleurisy with effusion, or pleural tumour, the intercostal space over the affected site becomes rigid. Rigidity of the chest increases in general in the aged due to ossification of the costal cartilages, development  the lung emphysema, and also with filling of both pleural cavities with fluid. Increased resistance of the chest can then be felt during examining the chest by compression in both the anteroposterior and lateral directions.

Palpation is used for determining the strength of voice conduction to  chest surface {fremitus vocalis s. pectoralis). Vocal fremitus depends on the conduction of voice sounds through the respiratory tract.

The palms of the hands  placed on the symmetrical parts of the chest and the patient is asked to i loudly a few words (with the letter ‘r’ in them to intensify vibration). The doctor can ask the patient to repeat words, such as “ninety-nine”, “one, two, three,” “eee-eee”. The patient should speak the words with a voice of uniform intensity. The voice should be as low as possible since voice vibrations are better transmitted by the air column in the trachea and the bronchi to the chest wall in this case. Vibrations are felt as the hands move symmetrically on either side of the sternum and vertebral column.

         Fremitus vocalis can also be determined by one hand as as well: the palm of the examining hand should be placed alternately on the symmetrical parts of the chest.

 

 

Determination of vocal fremitus (position of examiner’s hands)

 

In general vocal fremitus is the most intense in the regions of the thorax where the trachea and bronchi are the closest to the surface, particularly along the sternum between the first and second ribs and posteriorly between the scapulae. Progressing downward, the sound decreases and is least prominent at the base of the lungs.

Vocal fremitus is of about the same intensity in the symmetrical parts of the chest of a healthy person. Vocal vibrations are louder in the upper parts of the chest and softer in its lower parts. Moreover, voice conduction is better in men with low voice and thin chest; the vibrations are weaker in women and children with higher voice (and also in persons with the well developed subcutaneous fat tissues). Vocal fremitus can be stronger or weaker (or in some cases it can even be impalpable) in pathological conditions of the respiratory organs. In focal affections, vocal fremitus becomes unequal over symmetrical parts of the chest.

Vocal fremitus is intensified when a part of the lung or its whole lobe becomes airless and more uniform (dense) because of a pathological process.  According to the laws of physics, dense and uniform bodies conduct sound better than loose and non-uniform. Induration (consolidation) can be due to various causes, such as acute lobar pneumonia, pulmonary infarction, tuberculosis, accumulation of air or fluid in the pleural cavity, etc. Vocal fremitus is also intensified in the presence in the pulmonary tissue of an air cavity communicated with the bronchus.

 Vocal fremitus becomes weaker:

(1)   when liquid or gas are accumulated in the  pleural cavity; they separate the lung from the chest wall  to absorb voice vibrations propagating from the vocal slit along the bronchial tree;

(2)    in complete obstruction of the bronchial lumen by a tumour which interferes with normal conduction of sound waves to the chest wall;

(3)    in asthenic emaciated patients (with weak voice);

(4)    in significant thickening of the chest wall in obesity.

Low-frequency vibrations due to pleural friction (friction fremitus) in dry pleurisy, crepitation sounds characteristic of subcutaneous emphysema of the lungs, vibration of the chest in dry, low (low-pitch buzzing) rales can also be determined by palpation.

         

Decreased vocal fremitus in the upper airway may indicate a) the obstruction of a major bronchus, b) pneumo-, hydro-, haemothorax, c) emphysema of lungs, d) adiposity can also be the cause of decreased vocal fremitus.   The voice of fremitus is increased a) in pneumonia, b) in abscess, b) in atelectasis, c) in cavern.

Absence of fremitus usually indicates obstruction of a major bronchus, which may occur as the result of aspiration of a foreign body.

Decreased or absent fremitus is always recorded and reported for further investigation. During palpation other vibrations that indicate pathologic conditions are noted. One is a pleural friction rub, which has a grating sensation. It is synchronous with respiratory movements and is the result of opposing surfaces of the inflamed pleural lining rubbing against one another,

 

Percussion as a method of examination

Percussion is performed to evaluate the size, borders, and consistency of some internal organs; to detect tenderness; and to determine the extent of fluid in a body cavity. There are two percussion techniques: direct and indirect.

Direct percussion involves striking a finger or hand directly against the client’s body. The doctor may use direct percussion technique to evaluate the sinus of an adult by tapping a finger over the sinus, or to elicit tenderness over the kidney by striking the costovertebral angle (CVA) directly with a fist.

Indirect percussion requires both hands and is done by different methods depending on which body system is being assessed. Indirect fist percussion of the kidney, for example, involves placing the nondominant hand palm down (with fingers together) over the CVA and gently striking the fingers with the lateral aspect of the fist of the dominant hand.

Indirect percussion of the thorax or abdomen is performed by placing the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed. This finger is sometimes referred to as the pleximeter. The other fingers of that hand are spread apart and slightly elevated off the client’s skin so that they do not dampen the vibration. With the tip of the middle finger of the dominant hand (the plexor), the examiner strikes the distal interphalangeal joint, or just distal to the joint, that lies against the client’s skin. The tip of the striking finger hits the middle finger, which is against the skin, between the cuticle and first joint. Some examiners use both the index and middle fingers as plexors. The wrist must be relaxed and loose while the . pleximemer remains stationary. Rebound the plexor finger as  is it strikes the pleximeter so that the vibration is not lost. Listen for the vibrations created by one finger strikes to-other. Tapping produces a vibration 1.5 to 2 inches (4 to ~ deep in body tissue and subsequent sound waves). Per- two or three times in one location before moving to an-other position. Stronger percussion will be needed for obese or very – obese clients, because thickness of tissue can impair the vibrations; the denser the tissue, the quieter the percussion.

 Five percussion tones are described:

– Tympanic  isloud, high-pitched sound heard over the abdomen.

 – Resonance is heard over normal lung tissue, whereas

–         hyper-resonance is heard in overinflated lungs (as in emphysema).

–         – Dullness is heard over the liver, and

–         – flatness is heard over bones and muscle.

Detecting sound changes is easier when moving from resonance to dullness (e.g., from the lung to the liver). Indirect percussion can be mastered with practice.

 

Immediate percussion by different methods: generally adopted method; by Yanovsky; by Obrastsov

 

The lungs are percussed in order to evaluate the densities of the underlying organs. Resonance is heard over all the lobes of the lungs that are not adjacent to other organs. Dullness is heard beginning at the fifth interspace in the right midclavicular line. Percussing downward to the end of the liver, a flat sound is heard because the liver no longer overlies the air-filled lung. Cardiac dullness is felt over the left sternal border from the second to the fifth interspace medially to the midclavicular line. Below the fifth interspace on the left side, tympany results from the air-filled stomach. Deviations from these expected sounds are always recorded and reported.

Physical buckgrounds of percussion.

The organs and tissues lying beneath the percussed area begin vibrating and these vibrations are transmitted to the surrounding air. Liquids and airless tissues give dull sounds such as the percussed femur. The properties of each particular percutory sound depend on the amount of air or gas in it.

Percussion Tones

Mediate and immediate percussions

Percussion in done by tapping with a plexor on a pleximeter placed on the body, or by a finger on anothes  finger is named mediate percussion.  In immediate percussion the examined part of the body  is striken directly by the soft tip of the index finger.

 

Percussion of the chest

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In comparative percussing the chest, the anterior lung is percussed from apex to base, usually with the patient in the supine or sitting position. Each side of the chest is percussed in sequence in order to compare the sounds, such as the dullness of the liver on the right side with the tympany of the stomach on the left side. When percussing the posterior lung, the procedure and sequence are the same, although the patient should be sitting. Normally only resonance is heard when percussing the posterior thorax from the shoulder to the eighth or tenth rib. At the base of the lungs dullness is heard as the diaphragm is percussed.

The rules and technique of comparative percussion

A certain sequence is followed in comparative percussion. Percussion sounds over the lung apices (in the front) on the symmetrical points of the chest are first compared; the pleximeter finger is placed parallel to the clavicle. The plexor finger is then used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below the clavicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The plexor finger is then  used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below  the clawicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The percussion sounds are compared only  to the level of the 4^th rib along the medioclavicular line (and medially). The heart lying below this level changes the percussion sound. For comparative percussion of the axillary region, the patient should raise his arms and clamp the hands at the back of the head. Comparative percussion of the lungs on the back begins with suprascapular areas. The pleximeter finger is placed horizontally, while during percussion of the regions between the scapulae, the pleximeter should be vertical. The patient should cross his arms on the chest to displace the scapulae anteriorly (away from the backbone). During percussion of the points lying below the scapulae, the pleximeter should again be horizontal; in the interspace it should be placed parallel to the ribs

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The mechanism of development of pulmonary sound, dull and thympanic sounds

The percussion sound can change in pathological processes because of the decreased content or full absence of air in a part of the lung, and because of the pleural fluid (transudate, effusion, blood), increased airiness of the lung tissue, and the presence of air in the pleural cavity (pneumothorax).

 

 

The amount of air in the lungs decreases in

(1)   pneumosclerosis, fibrous-focal tuberculosis,

(2)    pleural adhesion or obliteration of the pleural cavity which interferes with normal distention of the lung during in­spiration; the difference in the percussion sound will be more pronounced at the inspiration level and weaker during the expiration;

(3)    lobular and especially confluent pneumonia, in which pulmonary tissue alternates with consolidations;

(4)    considerable oedema of the lungs, especially in the inferiolateral regions due to insufficient contractility of the left ventricle;

(5)    compression of the pulmonary tissue by the pleural fluid (compression atelectasis) above the fluid level;

(6)    complete obstruction of the large bronchus with a tumour and gradual resorption of air from the lungs below the closure of the lumen (obstructive atelectasis). Clear pulmonary sounds I become shorter and higher (i.e. duller) in the mentioned pathological conditions. If these conditions are attended by decreased tension in the elastic elements of the pulmonary tissue, e.g. in the presence of compression or obstructive atelectasis, the sound over the atelectatic zone becomes dull with a tympanic tone. This sound can also be heard during percussion of a patient with acute lobar pneumonia at its first stage, when the alveoli of the affected lobe, in addition to air, contain also a small amount of fluid.

A complete absence of air in the entire lobe of the lung or its part (segment) is observed in the following cases:

(a)   acute lobar pneumonia at the consolidation stage, when the alveoli are filled with the inflammatory exudate containing fibrin;

(b)   formation in the lung of a large cavity, which is filled with the inflammatory fluid (sputum, pus, echinococcous acid, etc.), or heterogeneous airless tissue (tumour

(c)   accumulation of fluid in the pleural cavity (transudate, exudate, blood). Percussion over airless parts of the lung or over fluid accumulated in the pleural cavity gives a soft short and high sound which is called dull or, by analogy with the percussion sounds of airless organs and tissues (liver, muscles), liver dullness. But the absolute dullness identical to the percussion sound of the liver can only be heard in the presence of a large amount of fluid in the pleural cavity.

The amount of air in the lung increases in emphysema. The percussion sound in lung emphysema is louder than the dull tympanic sound because of the increased airiness of the pulmonary tissue and decreased elasticity of the tense pulmonary tissues; but the tympanic character is preserved. The percussion sound resembles the one produced by a stroke on a box; hence the name bandbox sound.

The amount of air held inside the lung increases with formation in it of a smooth-wall cavity filled with air and communicated with the bronchus (abscess, tuberculotic cavern). The percussion sound over this area will be tympanic. If the cavity is small and situated deeply in the chest, vibrations of the pulmonary tissue will not reach this cavity and no tympanic sound will be heard. Such a cavity will only be revealed by roentgenoscopy. The sound over a very large smooth-wall cavity in the lung (6-8 cm in diameter) will be tympanic, resembling a stroke on a metal (metallic percussion sound). If this cavity is located superficially and is communicated with the bronchus through a narrow slit, the percussion sound will be soft and will resemble that of a cracked pot (hence the name—cracked-pot sound).

 

 

 

If you are having difficulty hearing percussion tones, how can your technique be improved?

The two technique errors seen most often with beginning learn­ers are contact of the nondominant hand and the delivery of the plexor finger.

■Only the middle finger of the nondominant hand should be in
contact with the percussion surface. Students tend to allow all
the fingers to be in contact. Get those fingers off!

■The plexor (striking finger) must get wrist action for a quick,
snappy, forceful strike. The strike should occur with the fin­
gertip, not the finger pad.

 

Topographic percussion

In topographic percussing the chest, the doctor looks for the lungs’ borders in the main lines, the location of the apex of the lung and width of Kroenig’s areas.

In topographic percussion the margin of the lung is assessed from the side of resonance sound.

          The upper margin of the lung (the location of the apex of the lung) is determined by percussions from the clavicle to the neck. The apex of each lung rises about 2 to 4 cm above the inner third of the clavicles in front of the body At the back we examine the location of the apex of the lung by percussions from the scapula axis to the seventh cervical vertebra. Normally, the upper border of the lung is in the seventh cervical vertebra at the back.

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          The width of Kroenig’s areas is determined by percussions from the middle of muscle trapezium to each direction (to neck and shoulder) to disappearance of the resonance. Normally, the width of Kroenig’s areas is 3-5 cm.

The excursion of the lung is the distance between the lower costal margin of the lungs in the maximum inspiration and maximum expirations. Normally, the excursion of the lung is 2-6 cm.

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The rules of the topographic percussion

During topographic percussion of lungs one should apply such rules as follows

–         the finger-pleximeter should be placed parallel to the border of the organ one is seeking for;

–         percussion should be carried out from resonans pulmonary sound to dull one.

–         If the lungs’ borders has being determined, they should be marked on the edge of the finger-pleximeter from the side of resonans pulmonary sound.

        

2. Definition of height of the lungs’ apexes.

The lungs’ apexes should be determined on anterior and posterior surface of the chest. To find out the height of the lungs apexes anteriorly percuss from the midpoint of each clavicle parallel to their axis in progressive steps downwards as well as quite medially untill dull percussiootes will be heared. Posteriorly percussion should be carried out from the center of suprascapular area in direction to the point, placed on 3-4 cm laterally to the 7^th cervical spinous processus. Iorm the apex of each lung rises anteriorly about 2-4 cm above the inner third of the clavicle, posteriorly – is placed approximately at the level of the 7^th cervical spinous processus.

Technique of Kroenig’s area width definition

The locations of the lungs apexes can be mentally projected onto the each shoulder – so-called Krenig’s area. To determine this zone one should use a quiet percussion, moving the finger-pleximeter from the center of trapezoid muscle across the top of each shoulder in direction both to the neck and to the shoulder joint. Percuss across the top  of each shoulder  to identify the approximately  5-cm band of resonance overlying each lungs apex. In healthy persons the width of dullness makes approximately 3-8 cm.

 

The upper border of the lung and width of the Kroenig’s area can vary depending on the amount of air in the apices. If the amount of air is high (for example, due to emphysema) the apices increase in size and move upwards. The Kroenig’s area  widens accordingly. The presence of connective tissue in the lungs apex (which usually develops during inflammation as in tuberculosis or pneumonia or inflammatory infiltration) decreases the airness of the pulmonary tissue. The upper border of the lung lowers and the width of the Kroenig’s area decreases.

 

Determination of the lower lungs borders and their mobility

To determine the lower lungs borders one should held the pleximeter finger parallel to the expected border of diaphragmatic dullness, percuss in progressive steps downwards on parasternal, midclavicular, anterior axillary, midaxillary, posterior axillary, scapular and paravertebral lines from the right and left side. Identify the level of diaphragmatic dullness on each side during quiet respiration. This level is often slightly higher on the right. Anteriorly the low border of the left lung on parasternal and midclavicular lines is not distinguished because of heart dullness.

The lower border of the right lung is as a rule at the point of transition of the clear pulmonary resonance to dullness (lung-liver border). In exceptional cases, when air is present in the abdominal cavity (e.g. in perforation of gastric or duodenal ulcer), liver dullness may disappear. The clear pulmonary resonance will then convert to tympany. The lower border of the left lung by the anterior and midaxillary lines is determined by the transition of clear pulmonary resonance to dull tympany. This is explained by the contact between the lower surface of the lung (through the diaphragm) and a small airless organ, such as the spleen and the fundus of the stomach, which give tympany (Traube’s space).

The position of the lower border of the lungs can vary in various pathological conditions that develop in the lungs, the pleura,  in diaphragm, and the abdominal viscera. The border can both rise and lower from the normal level. This displacement can be uni- or bilateral.

Bilateral lowering of the lower border of the lungs can occur in acute and chronic dilation of the lungs (attack of bronchial asthma and emphysema of the lungs, respectively) and also in sudden weakening of the tone of the abdominal muscles and lowering of the abdominal viscra (splanchnoptosis). Unilateral lowering of the lower border of the lungs can be due to vicarious (compensatory) emphysema of one lung with inactive tion of the other lung (pleurisy with effusion, hydrothorax, pneumothorax hemiparesis of the diaphragm).

The elevation of the lower border of the lungs is usually unilateral and I occurs in (1) shrivelling of the lung due to development of connective tissue (pneumosclerosis); (2) complete obstruction of the lower-lobe bronchus by a tumor which causes gradual collapse of the lung, atelectasis; (3) accumulation of fluid or air in the pleural cavity which displace the lung up wards and medially toward the root; (4) marked enlargement of the liver (cancer, echinococcosis), or of the spleen (chronic myeloleukaemia) Bilateral elevation of the lower borders of the lungs occurs in the presence I of large amounts of fluid (ascites) or air in the abdomen due to an acute  perforation of gastric or duodenal ulcer, and also in meteorism.

 

 

 

Key points of projection of the lungs’ low borders on the anterior and posterior chest include the following:

 

 

After determining the lower border of the lungs respiratory mobility of pulmonary borders should be determined by percussion during forced inspiration and expiration. The lungs lower borders mobility can be active or passive.

The active mobility is those observed at respiration, passive – at changes of patient’s position. Active mobility is usually measured by the difference in the position of the lower border of the lungs between the two extremes.

The active lower lungs borders mobility can be measured by noting the distance between the levels of diaphragmatic dullness on full expiration and full inspiration, normally around 5-6 cm.   Measurements are done by three lines on the right side (midclavicular, axillary, and scapular lines) and two lines on the left side (midaxillary and scapular lines). The normal variation of the lower border of the lungs is described by the figures given in the table. Mobility of the lower border of the left lung by the midclavicular line can not be determined because of the interference of the heart.

 

Determination of respiratory mobility of the lower lung border

 

The active mobility of lungs is quite different on different topographic lines and includes following:

 

 

Diagnostic importance of lungs  borders mobility

 The extension of the Kroenig’s area and rising of lungs apexes are observed at lungs emphysema; in the other hand, at tuberculosis, induration of lungs’ parenchima the sizes of lungs apexes decrease.

The location of lower lungs borders varies at various pathological conditions which can develop in lungs as well as in pleura, diaphragm and organs of abdominal cavity. Both descending and raising of lower lungs borders can be present, that phenomenon can be unilateral or bilateral. They descend at emphysema. An abnormally high level of low lungs’ borders one can suggest pleural effusion or a high diaphragm, as well as paralysis or atelectasis.

 

The short scheme of examiantion of a chest (inspection, palpation, percussion)

__ Assess when the patient is at rest, calm, and seated

__ Try to not let the patient realize you are watching their respirations. Check respiratory rate after you have assessed the radial pulse rate with your peripheral vision watching for each breath.

__ Listen for audible respiratory sounds like stridor or wheezes while you are assessing respiratory rate

__ Assess respiratory effort. Is the patient’s breathing labored? Are they using accessory muscles of respiration (Scalene muscles and Sternocleidomastoid muscles)? Are there intercostal retractions with inspiration?

__ Watch for chest wall expansion. Is expansion symmetric and equal on right and left sides?

__ Normal Respiratory Rate = 14-20 breaths per minute.

 

 Inspection

__ You already watched for symmetry of anterior chest wall expansion when you checked respiratory rate. Move behind the patient and also check for symmetry of posterior chest wall expansion.

__ Look for scars, rashes or other skin abnormalities on the chest wall.

B. Palpation (Chest Wall, Skin And Subcutaneous Structures, Chest Wall Expansion, and Tactile Fremitus)

__ Only do this on skin, not over a gown or article of clothing

__ Palpate the chest wall, note any areas of pain or tenderness

__ Palpate the skin and subcutaneous structures overlying the chest wall. You may find a lipoma or sebaceous cyst.

__ Stand behind the patient to check for chest wall expansion by:

__ Place your hands around the lower thorax (Warn the patient so that they are not surprised.)

__ Slide thumbs medially with a small skin fold

__ Ask patient to take a deep breath

__ Assess for symmetric movement (Normally 2 to 5 inches of expansion is observed)

__ Check for tactile fremitus by:

__ Have patient place their hands across their shoulders to pull the scapula laterally

 

__ You can check for tactile fremitus by using either:

__ the dorsal surface of your fingers or

__ the ulnar surface of your hands and fifth finger or

__ the balls of your hands (MCP joints)

 

 Percussion

__ This is a difficult technique to master. With percussion, you can determine if the tissues deep to the area of percussion are air filled, fluid filled, or solid tissue by the pitch, duration, and intensity of the percussed sound.

__ Only do this on skin, not over a gown or article of clothing

__ Room must be quiet for you to appreciate the percussed sound

__ Technique of percussion:

__ Hyperextend your index finger at the PIP and DIP joints and flex the index finger about 45 degrees at the MCP joint.

__ Place the DIP joint of your index finger on the patient’s upper chest in an

intercostal space

__ No other part of your hand should be in contact with the patient’s skin

__ Place your other hand near this hand

__ Use your other hand’s index or middle finger to quickly percuss at the DIP joint in contact with the patient’s skin. Use two or three brisk percussion strikes (flexing your hand at the wrist to percuss) and then quickly withdraw the percussing finger from the DIP

__ Always begin at the apex of the lungs

__ Always compare right side to left side at each level, then move inferiorly to percuss middle, lower and lateral posterior lung fields

__ Common errors of percussion:

__ Examiner places their entire hand on patient’s chest

__ Examiner’s DIP, PIP, and MCP joints of their middle or index finger is flat against the patient’s chest

__ Examiner percusses/strikes at their DIP with the other hand from too far away from the chest wall

__ Examiner does not strike vigorously enough to make an audible sound

__ Examiner does not assure the room is quiet enough to hear the percussed sound

__ Examiner percusses one entire lung, and then percusses the other lung

__ Examiner does not ask the patient to cross their arms across their chest to move their scapula laterally