ROCKY VISTA UNIVERSITY

PCM I

RESPIRATORY EXAM

Principles of Clinical Medicine
Afia Ukor, DO
ROCKY VISTA UNIVERSITY

Page 2: Reading Material

• Reading List:

  • Bates’ Guide to the Physical Examination and History Taking – 13e, ch 15 pp 441-448

  • Respiratory Section of PCM Lab Manual

Page 3: Objectives

• Identify the anatomic structures in the respiratory system including bony structures, lobes, fissures, trachea, and bronchi.

• Demonstrate the use of location descriptors (e.g., midsternal line) to enhance written descriptions of abnormal lung findings during physical exams.

• Describe the physiologic changes that occur during normal respiration.

• Demonstrate tactile fremitus and percussion techniques, recognizing normal vs. abnormal findings.

• Describe normal auscultatory findings during respiratory examinations.

• Comprehend the pathophysiological processes involved in producing adventitious and transmitted voice sounds and how they are elicited.

Page 4: Anatomy of the Respiratory System

• Key Anatomic Landmarks:

  • Suprasternal notch

  • Manubrium

  • Sternal angle (Angle of Louis)

  • Manubriosternal joint (Approximately 5 cm below the notch)

  • Body of sternum

  • Costal cartilages

  • Xiphoid process

  • Costal angle

Page 5: Anatomy of the Ribs

• Rib Classifications:

  • Ribs 1-7: Articulate directly with the sternum (true ribs)

  • Ribs 8-10: Attach via costal cartilage (false ribs)

  • Ribs 11-12: Floating ribs (no anterior attachments)

• Anatomical Reference:

  • The inferior tip of the scapula generally aligns with the level of T7 spinous process or the 7th rib/interspace.

Page 6: Anatomy of the Trachea

• The trachea bifurcates at the carina located at the sternal angle anteriorly, and at the level of T4 spinous process posteriorly.

Pages 7-9: Anatomical Lines on the Chest

• Lines Describing Chest Locations:

  • Midsternal line: Precise line dropping from the mid sternum.

  • Midclavicular line: Estimated line dropping vertically from the mid-point of the clavicle.

  • Anterior axillary line: Estimated line dropping from the anterior axillary fold (muscle boundaries of the axilla).

  • Midaxillary line: Estimated line dropping from the apex of the axilla.

  • Posterior axillary line: Estimated line dropping from the posterior axillary fold.

  • Vertebral line: Precise line that overlays the spinous process.

  • Scapular line: Estimated line dropping from the inferior angle of the scapula.

Page 10: Anatomical Locations on the Chest

• Regions Identified in Chest Examination:

  • Supraclavicular region: Above the clavicles

  • Infraclavicular region: Below the clavicles

  • Interscapular region: Between the scapulae

  • Infrascapular region: Below the scapulae

  • Lung bases: The lowermost sections of the lungs.

Page 11: Anatomy of Lung Lobes and Fissures

• Lung Anatomy:

  • Apex: Positioned 2-4 cm above the inner 1/3 of the clavicle.

  • Right Lung Lobes:

    • Upper lobe

    • Middle lobe

    • Lower lobe

  • Left Lung Lobes:

    • Upper lobe

    • Lower lobe

Page 12: Lung Fissures

• Lung Borders:

  • Anterior: Lower border crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line.

  • Posterior: Lower border is around the level of T10 spinous process.

• Both borders descend during inspiration.

Page 13-14: Lung Field Locations

• Identification of Lung Fields and Anatomical Relationships:

  • Observations in the right upper lung field most likely originate from the right upper lobe.

  • Signs laterally in the right middle lung field may derive from any of the three right lobes.

  • Similar queries about left upper lung field locations along the midclavicular line.

Page 15: Anatomical Fissures and their Functions

• Fissures of the Lungs:

  • Oblique Fissure: Divides the lung roughly in half, extending from T3 spinous process to the 6th rib at the midclavicular line.

  • Horizontal (Minor) Fissure: Divides the right lung into a minor fissure running close to the 4th rib and meeting the oblique fissure near the 5th rib in the midaxillary line.

Page 16: Anatomy of the Pleurae and Diaphragm

• Pleurae Types:

  • Visceral pleura: Covers the lung's surface.

  • Parietal pleura: Lines the thoracic cavity.

• Diaphragm:

  • Primary muscle of inspiration; contractions during inhalation descend into the thoracic cavity, enlarging it.

  • Accessory Muscles of Inspiration:

    • Parasternals

    • Scalenes

    • Expand the thorax during inhalation.

Page 17-18: Physiology of Breathing

• Inspiration Process:

  • Diaphragm descends into the chest cavity

  • Decrease in intrathoracic pressure attracts air through the tracheobronchial tree into the alveoli.

  • The lungs expand, allowing oxygen to diffuse into the bloodstream.

• Exhalation Process:

  • Recoil of chest wall and lungs.

  • Relaxation of diaphragm and passive ascent.

  • Air flows outward, and the chest/abdominal cavities revert to resting positions.

  • During exercise or lung disease, auxiliary muscles become engaged to assist in breathing effort.

Page 19-20: Anatomy Question: Pneumonia Signs

• Anatomy Question Example:

  • Signs of pneumonia found in the right middle lung field (mid-axillary line):

    • A) Only the Right Upper Lobe

    • B) Only the Right Middle Lobe

    • C) Only the Right Lower Lobe

    • D) Any of the lobes on the right (upper, middle, or lower)

    • E) Lung sounds are never heard here.

Page 21: Techniques of Examination

• Patient Positions During Exam:

  • Sitting

  • Supine

  • Unable to sit up without assistance

Page 22: Inspection Techniques

• Inspection Factors:

  • Rate, rhythm, depth, symmetry, shape, and effort of breathing

  • Normal respiratory rate for adults: 12-20 breaths per minute.

  • Observe for signs of respiratory difficulty:

    • Use of accessory muscles or retractions (supraclaviular or subcostal).

    • Tracheal position (assess for displacement indicating potential pneumothorax).

    • Assess color for cyanosis (signs of hypoxia) in lips, fingers, and toes.

  • Look for indicators of chronic disease:

    • Clubbing of fingers

    • Barrel chest indicating COPD

  • Listen to the patient's breathing sounds.

Page 23: Inspection: Thoracic Deformities

• Thoracic Deformities to Note:

  • Funnel Chest: (Pectus excavatum)

  • Pigeon Chest: (Pectus carinatum)

  • Kyphosis

  • Barrel Chest

Pages 24-27: Examples of Deformities

• Funnel Chest (Pectus Excavatum):

  • Discussed in relation to minimally invasive procedures for correction.

• Pigeon Chest (Pectus Carinatum):

  • Clinical insights into management.

• Kyphosis:

  • Reflected in pediatric orthopaedics literature.

• Barrel Chest:

  • Examination of standard measurements and implications in clinical settings.

Page 28: Palpation Techniques

• Palpation of the Chest:

  • Focus on tenderness including:

    • Intercostal tenderness (indicative of inflamed pleura).

    • Bruising over fractured ribs.

    • Tenderness of costal cartilage and sternum due to rib somatic dysfunction.

    • Abnormalities in overlying skin (e.g., masses).

Page 29: Respiratory Expansion Palpation

• Technique for Chest Expansion:

  • Position thumbs at the level of the 10th ribs, fingers grasping loosely along the lateral rib cage.

  • Instruct the patient to inhale deeply while observing and feeling for symmetry in expansion.

Page 30: Palpation: Tactile Fremitus

• Tactile Fremitus:

  • Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall, perceived when the patient speaks (usually felt in those with clear lungs).

  • Optimal vibratory sensitivity achieved using thenar/hypothenar eminences.

  • Patient is asked to repeat phrases like "99" or "one-one-one" to assess.

Page 31: Tactile Fremitus Continuation

• Prominence in Tactile Fremitus:

  • More prominent in the intrascapular area and on the right side compared to lower lung fields (posterior examination).

  • Anterior Examination:

    • Decrescent or absent over the cardiac area.

  • Abnormal Findings:

    • Increased fremitus suggests consolidation is present (e.g., pneumonia).

    • Decreased or absent fremitus may indicate obstruction, pleural effusion, and pneumothorax.

Page 32: Palpation: Percussion Technique

• Percussion Technique Instructions:

  • Hyperextend the middle finger and press the distal interphalangeal joint firmly against the chest surface, keeping other fingers off.

  • Introduce a quick, sharp yet relaxed wrist motion when striking to create vibration without damping.

Page 33: Percussion Notes

• 
  

• Types of Percussion Sounds:
  

  NAME OF SOUND	Relative Intensity	Relative Pitch	Relative Duration	Quality	Location
  Flatness	Soft	High	Short	Very Dull	Thigh
  Dullness	Medium	Medium	Medium	Thud	Liver
  Resonance	Loud	Low	Long	Hollow	Normal lung
  Hyperresonance	Very loud	Lower	Longer	Boom	None normally
  Tympany	Loud	High	Medium	Drum	Gastric bubble or puffed out cheeks
  Page 34: Additional Percussion and Auscultation Points

  • Areas for Percussion/Auscultation:

    • Instructional guidelines presented to enhance clinical assessment skills.

  Page 35: Percussion and Dullness

  • Dullness Location:

    • Heart creates an area of dullness to the left of the sternum from the 3rd to 5th intercostal spaces (ICS).

    • Recognizing effusions may be more challenging when examined anteriorly because pleural fluid settles at the lowest parts of the pleural space.

    • Dullness from right middle lobe pneumonia typically located behind the right breast unless breast tissue is displaced.

  Page 36: Diaphragmatic Excursion

  • Dullness vs. Resonance:

    • Dullness replaces resonance when fluid or solid tissue fills air-containing lung spaces.

    • Measure diaphragmatic excursion by assessing the level of dullness on full respiration, with a normal range of $5-6$ cm.

    • An abnormally high level indicates possible pleural effusion or elevated diaphragm.

  Page 37: Auscultation of Normal Lung Sounds

  • 
    

  • Auscultation Findings:
    

    LUNG SOUNDS	Duration of Sounds	Intensity of Expiratory Sounds	Pitch of Expiratory Sounds	Location Normally Heard
    Vesicular	Inspir. > Expir.	Soft	Low	Over most of both lungs
    Bronchovesicular	Insp. = Expir.	Intermediate	Intermediate	1st/2nd ICS anterior & between scapulae
    Bronchial	Expir. > Insp.	Loud	High	Manubrium
    Tracheal	Insp. = Expir.	Very loud	High	Over trachea
    Page 38: Auscultation Techniques

    • Listening Technique:

      • Use the diaphragm of the stethoscope, alternating sides for comparison.

      • Have the patient hug their arms across their chest to allow better access to the posterior thorax.

      • Instruct the patient to take deep breaths with an open mouth.

    Page 39: Auscultation: Identifier and Adventitious Sounds

    • Auscultatory Dismissal:

      • Identify breath sounds and any adventitious sounds (additional sounds).

      • Typically, sounds are louder in lower posterior fields.

      • Decreased Breath Sounds:

        • Result from decreased airflow (obstructive lung disease or muscle weakness).

        • Indicated when the transmission of sound is poorly transferred (pleural effusion, pneumothorax, emphysema).

    Pages 40-43: Adventitious Sounds and Their Meaning

    • Types of Adventitious Sounds:

      • Wheeze/Rhonchi:

        • Wheeze: High-pitched sound happening when air passes through narrowed bronchi.

        • Rhonchi: Low-pitched, occurring in the presence of secretions in larger airways.

      • Stridor:

        • A wheeze predominantly during inspiration, louder in the neck than chest wall, indicating partial obstruction of the larynx or trachea requiring immediate attention.

      • Crackles/Rales:

        • Fine crackles: Soft, high-pitched sounds caused by the opening of deflated small airways during inspiration, often seen in interstitial lung disease and early congestive heart failure (CHF).

        • Coarse crackles: Louder, lower-pitched sounds due to air bubbles passing through secretions or narrowed airways; typically caused by chronic bronchitis or pneumonia.

      • Pleural Rub:

        • Produces crackling sounds, usually localized and painful, typically indicative of inflamed, roughened pleural surfaces (pleuritis).

    Pages 44-45: Transmitted Voice Sounds

    • 
      

    • Normal vs. Abnormal Transmitted Voice Sounds:
      

      TYPE	NORMAL	ABNORMAL
      Bronchophony	"99" is muffled and indistinct	"99" is louder; clearer voice sounds
      Egophony	"ee" heard as muffled long E	"ee" changes to an "ay" sound (E to A change)
      Whispered Pectoriloquy	Whispered "1-2-3" is faint and indistinct	"1-2-3" is louder; clearer whispered sounds
      Page 46: Documentation of Findings

      • Recording Findings Example:

        • “Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.”

        • “Thorax symmetric with moderate kyphosis & increased AP diameter, decreased expansion. Lungs are hyper-resonant. Breath sounds distant with delayed expiratory phase & scattered expiratory wheezes. Tactile fremitus is bilaterally decreased; negative bronchophony. Diaphragm descends 2 cm bilaterally.”

      Page 47: Summary of Key Concepts

      • Summarized Learnings:

        • Anatomy and location descriptors are crucial in understanding the origins of lung findings.

        • Respiration is dynamic; familiarity with normal physiological presentations aids in recognizing abnormalities.

        • Tactile fremitus and percussion complement palpation to deepen the understanding of lung conditions.

        • Various disease processes yield distinct adventitious lung sounds.

        • Three examination maneuvers: bronchophony, egophony, and whispered pectoriloquy, assist in identifying lung consolidation.

      Page 48: References for Lung Sounds

      • Resources for Auditory Learning:

        • Bates' Lung Sounds - Library Access

        • LWW Health Library – Library Access

        • YouTube Medzcool Lung & Breath Sounds - Videos with sounds and explanations

        • EasyAuscultation – Free lessons for introductory or basic sounds, with paid advanced sounds.